The Mystery of Flight 427

by Bill Adair

  Cognitive failure. That was a delicate way of saying the pilots screwed up.

  The letter said there were numerous examples of accidents caused by pilots stomping on the wrong pedal. The 1985 crash of a Midwest Express DC-9 was caused by pilots who responded to an engine failure by pushing the rudder the wrong direction. A 1992 Air National Guard crash of a C-130 was caused by the same mistake. The letter asked Haueter to explore Emmett’s and Germano’s backgrounds to see if they had been trained to use the rudder or had flown other planes in which they would have used it more heavily. The letter said Haueter also should look into the fact that the pilots pulled back on the control column.

  Haueter had mixed feelings about whether they would have stomped on the rudder pedal. His ride in M-Cab had made him doubt that two seasoned pilots would have made such an obvious error. But like the Boeing engineers, he was concerned about pilots becoming too complacent in modern cockpits. Unlike the “stick-and-rudder” pilots of the old days, modern crews had become too much like computer programmers. They relied heavily on the autopilot and flight-management computers, which could practically fly an entire trip. So Haueter agreed to delve more deeply into Emmett’s and Germano’s training. Besides, the investigation had sunk into a lull and he had been looking for something to get everybody thinking again. The letter was just the jolt he needed. He faxed a copy to the pilots union.

  It didn’t take long to get the predictable response. ALPA went ballistic. Suggesting that pilots screwed up was akin to shouting a racial slur at them. Herb LeGrow, ALPA’s coordinator for the crash investigation, thought that Boeing was looking for a scapegoat. “We don’t want to see the reputations of the pilots compromised because [the safety board] can’t find an answer to what caused the accident,” he said in an interview in his Clearwater, Florida, home. LeGrow, a USAir 767 pilot who had worked on more than a dozen accident investigations, was also worried that Boeing would use its Washington clout to pressure the NTSB into blaming the pilots. He said ALPA might be small, but it was not afraid to go head to head with Boeing. “It’s David and Goliath at this point. If it gets down and dirty, I’m willing to fight. We’ll sharpen up our slingshots and fight them.”

  LeGrow and Cox fired off a letter to the safety board saying that Boeing was trying to raise doubts about the pilots and divert the investigation. The letter countered each point that Boeing had made. It said the cockpit tape showed that the pilots were not overreacting to the wake turbulence but were “struggling in an attempt to gain control of an uncontrollable aircraft.” The letter said it was unfair to make a comparison with military crews because airline pilots fly considerably more hours. In ALPA’s view, there was no need for a further exploration of Emmett’s and Germano’s backgrounds because the investigation so far “revealed that these individuals were fully qualified and had exemplary records.”

  LeGrow and Cox said there was no connection between the USAir crash and the pilot-error accidents cited by Boeing. The Midwest Express and C-130 crashes were engine failures at low altitude. “In USAir 427, there is no evidence that the flight crew applied an inappropriate flight control input. In fact, there is a significant amount of evidence which could lead to the conclusion that the aircraft experienced a mechanical malfunction.” The ALPA letter also defended the pilots for pulling back on the control column: “It should be noted that at the onset of the event, traffic beneath USAir 427 was a real issue. At that point, maintenance of altitude was, in fact, critical. No action by the crew could have stopped the roll…. By the time control column position became an issue, ground impact was inevitable.”

  LeGrow concluded the letter by saying that the pilots “fought for the lives of their passengers” and suggested that Boeing’s letter was written by its lawyers: “Everyone recognizes the manufacturer’s product liability problem. The issues of civil litigation should not be allowed to infiltrate an NTSB investigation. The traveling public deserves the answers to what truly caused this accident.”

  McGrew was not surprised that ALPA had a near meltdown over the Boeing letter. That was typical of the union, he thought. It always seemed to want to protect the brotherhood, even when the facts might suggest otherwise. It seemed as if ALPA wanted to perpetuate a myth that every pilot was perfect and never made mistakes.

  The roots of ALPA’s defensiveness about pilot error dated back to the late 1920s and early 1930s, when airline managers pushed pilots to fly long hours and take risks in dangerous weather. Pilots who tried to be safe often got fired. At least twelve of ALPA’s twenty-four founders were killed in accidents. But when a plane crashed, “pilot error” seemed to be the government’s automatic response. Rarely, if ever, did the airline get blamed, even if it had ordered the pilot to fly into a snowstorm. It was easy to blame dead pilots because they could not defend themselves. Ever since then, one of ALPA’s fundamental principles has been to clear the names of dead pilots.

  When an ALPA member got blamed for a crash, it was a black eye for the entire organization. The union also had a stake because it acted like a law firm, defending pilots who were accused of violating federal air regulations. That was part of the reason for such high union dues (about $4,000 per year for a 737 captain). If pilots got into trouble, the union provided a lawyer and a technical representative (a pilot such as Cox) who defended the accused during the hearings and appeals. The union was good at representing its members, often convincing airlines and the FAA that they should reduce or drop charges, but that effectiveness made people at the NTSB, the FAA, and Boeing skeptical when ALPA said it would be unbiased in a crash investigation. How could the union defend its members and be unbiased?

  It was rare that you ever saw Cox sweat, let alone make a mistake. He had tremendous self-confidence, which is why you felt so good with him in the captain’s seat. But on one flight in 1973, he got so frightened that he was afraid everyone on the plane was going to die.

  He was nineteen, home from college for Christmas break and flying occasional trips as copilot on a Cessna 421, a two-engine propeller plane. On one flight he was assigned to be copilot to take several businessmen from Birmingham, Alabama, to Erie, Pennsylvania. The plane was heavily loaded with people and luggage, so Cox and the captain planned to stop in Pittsburgh and refuel. The plane picked up ice as it descended through the clouds to Pittsburgh, but they were not worried. Rubber boots on the leading edge of the wings inflated to crack the ice so it would fall off, and the propellers were heated so ice wouldn’t build up on the blades.

  They landed in Pittsburgh without difficulty and spent about thirty minutes getting refueled. On the ground, they made a cursory check of the weather, but only for Erie. They had gotten through the clouds around Pittsburgh without difficulty and figured the weather there was no big deal.

  They took off and started to climb back through the same clouds, which topped off at 5,800 feet. As they climbed, they realized that the small Cessna was taking on a tremendous amount of ice. It got so thick on the wings that the boots stopped working. Then they heard a horrible sound like a machine gun. Bam-bam-bam-bam-bam-bam. It was the sound of the propellers hurling ice at the fuselage. The ice was building up so fast that the plane was getting dangerously heavy. They had the engines at full power, but the plane could barely climb.

  Cox looked out the window and saw ice growing on the wingtip fuel tanks. It was forming a menacing-looking icicle a foot and a half long and growing by the minute. Another blob of ice had developed on the spinner, the hub at the center of the propeller blades, and it too was growing. The windshield was so covered with ice that it was opaque, and the pilots had diverted all the heat in the plane to the vents on the windshield. That made the cockpit extremely hot and left the passengers freezing in the back, but it was having little effect on the windshield. If Cox or the captain wanted to look outside, he had to squint through a tiny strip right above the vents where the ice had melted. Cox was sweating a lot—a combination of heat and fear.

  The ice was so
thick and heavy that the plane lost its ability to climb, even at maximum power. Cox and the captain discussed what they should do. They didn’t want to return to Pittsburgh because they would have to go back through the nasty clouds. So they decided to continue to Erie, where the weather was slightly better. At that point, Cox wondered if they would survive. He wasn’t thinking about dying, exactly. He was worrying about what would happen if they had to set the plane down in trees. It would rip the aircraft apart. At that point, dying would be a foregone conclusion.

  As the captain flew the plane, Cox radioed to air traffic controllers, telling them the plane had a severe ice problem and that they were descending to the MOCA—the minimum obstacle-clearing altitude. It was the lowest they could fly and not worry about crashing into mountains and radio towers. Now that they were descending, the ice appeared to stop growing. It hadn’t shrunk, but at least it wasn’t getting worse. Cox was sweating so much now that he had soaked through two shirts. He normally wore his shirts buttoned all the way up and his ties tight around his neck, but now he had the collar unbuttoned and his tie loosened. His heart was racing.

  When he flipped the lever to lower the landing gear, he heard the strain of the electric motors trying to open the gear doors. Grind, grind, grind. Then he realized what was happening: The doors had been frozen shut by the thick layer of ice on the belly of the plane. The pilots might never get the gear down. They would have to make a belly landing.

  Grind, grind, grind. It sounded like the motors were ready to give up. Crack! The right gear door burst through the ice and opened. The gear went down. The plane wobbled a bit from the sudden drag on the right side of the plane.

  Crack! The left door opened and down went the gear. They could land now… if they could only see the runway.

  The captain had used the instrument landing system to line up and descend toward the runway. The ILS was designed for moments precisely like this one, so pilots could approach a runway without seeing it until the last minute. They squinted through the slit in the windshield, searching for the runway lights. As they finally saw the lights and prepared to land, Cox was thinking, If we keep the plane lined up, we should be okay.

  Thirty feet above the runway, the plane stalled and plunged nose down toward the pavement. There was so much ice that it changed the aerodynamics of the aircraft and made it stall sooner than expected. The captain pushed the throttle lever forward and jerked back on the control column to bring up the nose.

  Bam! The plane hit the runway on all three landing gear simultaneously. Ice broke from the belly and smashed into a million pieces on the runway. They taxied the plane to the terminal and opened the door. As the passengers got off, they teased the captain about the hard landing. “That was one of your worst,” one passenger said. Cox and the captain gave each other a knowing look. If the passengers only knew how close they had come to dying!

  Thinking back on that flight, Cox could see several mistakes. They were in a hurry and got careless. They didn’t check the weather reports as thoroughly as they should have. They should never have flown in such bad conditions. Cox’s willingness to admit when pilots made mistakes was one of the reasons he was so well respected at the NTSB. He represented a new generation of ALPA investigators, one that was not so protective of pilots.

  Yet, in the case of Emmett and Germano, Cox resisted any suggestion that they were to blame. He would grudgingly concede that it had been a mistake for them to pull back on the stick, but he would quickly add that it was an understandable response. At that point, they were watching the ground loom closer and closer. It was natural that they would want to pull the nose up to survive. Besides, Cox said, there was no procedure for pilots to follow if they had a rudder hardover. Such a situation was not mentioned in the pilots’ manuals, and it was not covered in their training. Plus, Emmett and Germano had had virtually no time to diagnose the problem and then decide what to do; it was only eight to ten seconds from the first bump caused by the wake turbulence until the plane was unrecoverable.

  Pilot-error accidents have been around as long as there have been pilots. Modern statistics show that pilots are the primary cause in about 70 percent of commercial jet crashes. In a 1992 Anniston, Alabama, crash that Haueter investigated, the captain, a new employee of the airline, became subservient to the first officer. They were both trying to be cool and calm, ignoring the fact that neither of them knew where the airport was. At one point the captain said, “Hopin’ no one on here’s a pilot,” an indication that he hoped passengers wouldn’t notice the strange flight path they were taking. Both pilots were lost but would not admit it. They thought they were south of the Anniston airport, but they were actually north of it. The plane crashed in trees seven miles from the airport, killing the captain and two passengers.

  Other pilot-error crashes are caused by simple mistakes, often in combination with faulty warning systems. In the Delta 1141 crash that Haueter investigated in Dallas, the pilots forgot to set the flaps, a critical step that gives the wings extra lift for takeoff. That alone should not have caused the crash, since the pilots had to go through a checklist to make sure the flaps were set and the Boeing 727 had a warning system that would sound an alarm if they started a takeoff roll without the flaps extended. But the pilots were rushing during the checklist. When the flight engineer called, “Flaps?” the first officer responded, “Fifteen-fifteen-green light” without actually looking to make sure they were set. The takeoff warning system should have sounded a horn about that mistake, but it had been having intermittent problems and did not sound as the plane started to take off. The plane got twenty feet off the ground, bounced tail-first at the end of the runway, and crashed into an antenna, killing fourteen people.

  The numbers on pilot error can be misleading because not many crashes can be attributed to a single factor. Investigators often say a crash is the result of many links in a chain. If any link had been broken, the accident would not have happened. The pilots may make the ultimate mistake, but they may be responding to bad weather, malfunctions in the plane, poor design in the cockpit, lack of training, inaccurate information from air traffic controllers, or a lack of proper rules from the FAA. If that takeoff warning system had been working, the captain of Delta 1141 probably would have stopped the plane safely on the runway. In Why Airplanes Crash, authors Clinton Oster, John S. Strong, and C. Kurt Zorn write that pilot error was the initiating factor in only 11 percent of airline crashes from 1979 to 1988.

  Airplane manufacturers have been remarkably successful at reducing pilot-error accidents with new warning systems that tell pilots when they are in trouble. The devices are like fussy robots in the cockpit that shout at the pilots when there is trouble nearby. All airliners in the United States now have a traffic collision avoidance system, or TCAS, that shows other planes on a screen and yells “TRAFFIC! TRAFFIC!” when one gets dangerously close. (That warning was heard on Flight 427’s cockpit tape as the USAir plane began to spiral down, probably because the TCAS saw the Jetstream plane a few miles away.) Big jets also are equipped with a ground-proximity warning system that hollers “TERRAIN! TERRAIN! PULL UP!” when a plane gets too close to the ground or a mountain. Those kinds of accidents—known as controlled flight into terrain, or CFIT—have dropped by 43 percent since the warning systems were mandated.

  As chairman of the human-performance group, Malcolm Brenner had to explore Boeing’s suspicions about the pilots. The cousin of comedian David Brenner, he was the most eccentric person involved in the investigation. A towering six-foot-three psychologist, Brenner had a quick wit and seemed more like a college professor than a crash detective. He got so excited when he discovered good data that he got chills. When it was exceptionally good data, he felt the hair stand up on the back of his neck. He spoke of humans the same way a zoologist talked about giraffes or elephants. Humans were the species that he studied. Never mind that he was one, too.

  Brenner grew up in West Philadelphia, studied psychology at Boston
University, earned his master’s degree at Stanford University, and received his Ph.D. from the University of Michigan. Before he landed the job with the NTSB, he had worked as a psychologist for NASA, an undercover private detective, a limo driver, and a Santa Claus. He said his biggest contribution to highway safety was when he quit being a limo driver.

  In the engineer-dominated world of accident investigation, the human-performance experts were the odd ducks. Other investigators dealt with solid, indisputable evidence—bent fan blades that told whether an engine was spinning or a broken gauge that showed a plane’s airspeed when it crashed. But human performance dealt with fuzzier issues—what a human did and why.

  In the initial probe, the NTSB had tracked down Emmett’s and Germano’s friends, coworkers, relatives, and everyone else who had seen the pilots before the crash. They were asked about the pilots’ moods, what they ate for breakfast and dinner, even how much they slept. A safety board handbook said such checks were important because “it is often possible to find problems in the individual’s background that foretell the problems of the accident.”

  Brenner found that Germano, forty-five, had been happily married for nineteen years and had two young children. He had been a pilot for the air force, Pilgrim Airlines, and Braniff before joining USAir. He had a clean FAA record, no criminal history, and he rarely drank. His pilot training records were generally positive, with comments such as “very consistent and smooth pilot,” “nice job,” and “excellent landings.” The only negative comment had come years earlier from a check pilot who wrote that he rated Germano in the “lower 10 percent.”