by Bill Adair
When Hall reconvened the meeting, board members asked the investigators a few more questions. The questions indicated that they had no major disagreements with the report.
Hall then read the conclusions, the thirty-four findings that built the case for the probable cause. The entire room—the Boeing engineers, the USAir officials, the reporters, Brett and the other family members, Haueter and his staff—had waited nearly five years for this moment.
The USAir Flight 427 flight crew was properly certificated and qualified…. No evidence indicated any preexisting medical or behavioral conditions that might have adversely affected the flight crew’s performance.
The first set of conclusions dealt with what had not happened, to show that the NTSB had ruled out bombs, birds, and a midair collision. The conclusions were designed to satisfy the conspiracy theorists who still believed someone had blown up the plane.
USAir flight 427 did not experience an in-flight fire, bomb, explosion or structural failure.
Hall moved on to the findings that built the case for the valve reversal. He read Conclusion No. 8, which even Boeing could support:
About 1903:00, USAir flight 427’s rudder deflected rapidly to the left and reached its left aerodynamic blowdown limit shortly thereafter.
The next finding ruled out pilot error. All of Boeing’s lobbying—the hours and hours of phone calls, the visits from company executives, the “Boeing Contribution,” and all the rides in M-Cab—had failed to persuade the safety board.
Analysis of the human performance data, including operational factors, does not support a scenario in which the flight crew of USAir Flight 427 applied and held a full left rudder input until ground impact more than 20 seconds later.
Hall switched gears and read several conclusions about the Colorado Springs crash. It was an extraordinary moment. The board was reopening the eight-year-old investigation and declaring that it had solved the mystery.
Analysis of the CVR, Safety Board computer simulation, and human performance data, including operational factors, from the United Flight 585 accident shows that they were consistent with a rudder reversal.
When Hall got to the conclusion that blamed the Colorado Springs crash on a reversal, the families broke into applause. But Hall admonished them, “Please, no demonstrations.”
He then read the probable cause statement for the USAir crash—four and half years of investigation boiled down to two sentences:
The probable cause of the USAir Flight 427 accident was a loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder power control unit servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide.
Translation: The rudder probably reversed. The fault was with the airplane, not the pilots.
“Any comment or discussion?” Hall asked, but no one replied. “If not, do I hear a motion that the findings and probable cause be adopted?”
Hammerschmidt made the motion and Francis made the second.
“Seconded,” Hall said. “All in favor, please signify by saying ‘aye.’”
“Aye.”
“Aye.”
“Aye.”
“Aye.”
“The findings and probable cause are unanimously adopted by the National Transportation Safety Board,” Hall said.
Behind him, Smith grinned at Daniels and raised her eyebrows in relief.
In the audience, some family members wept. Others choked back their tears.
Hall invited the board members each to make a final statement. Francis spoke of the importance of flight data recorders. Hammerschmidt said the investigation provided valuable research on wake turbulence. Black said it had been a frustrating experience.
“We engineers normally like to base our decisions on hard, cold facts—measurable things, things we can lay our hands on,” he said. “And while there is much evidence in these accidents, the vast majority of it is not hard, cold evidence.” He said he and his family often flew 737s and that the plane had “a good, documented safe history. There’s an awful lot of successful flights out there.”
As Black left the stage, he told reporters he had misgivings about the case. “I damn near voted against it,” he said. “This is a circumstantial case.”
Hall, renowned for blasting the FAA and Boeing, was uncharacteristically muted. He told reporters that he flew 737s every week, an endorsement of their safety. His only strong comments dealt with the FAA’s sluggishness on flight data recorders. He said little about the rudder. (He later said he was subdued because he did not want to anger the FAA before it began the 737 engineering study.)
After the meeting, Boeing officials held a news conference in the only meeting room they could find in the small hotel—the bar. The company took a conciliatory approach on the 737 report, and no longer pushed the pilot-error theory.
“We respect the board’s opinion,” said Charlie Higgins, Boeing’s vice president for airplane safety. He said new rudder valves being installed in 737s “completely eliminate any possibility of a reversal.”
The company will “do everything we can to look at the 737 rudder system and see if there is anything that can be improved,” he said. Higgins looked to the back of the room where several family members stood, and acknowledged their loss.
“I’d like to sincerely offer our condolences to the families,” he said. “It’s small consolation to them, but I believe this accident has improved aviation.”
Out in the hallway Brett said he felt vindicated.
“Pretty hard-hitting,” he said to his lawyer, Mike Demetrio.
“I agree,” Demetrio said. “They took the approach that the plane was deficient from Day One.”
Demetrio said some people were worried that the board would cave to pressure from Boeing, but that didn’t happen. “Today, I think the taxpayers got their money’s worth from the federal government,” he said.
Brett stepped inside the temporary NTSB office across from the ballroom and thanked several of the investigators. He told Loeb, “I really appreciate your being vocal yesterday.”
“That’s what they pay me to do,” Loeb said.
A few minutes later Brett said he was pessimistic that Tom McSweeny, the FAA official in charge of airplane certification, would agree with the NTSB’s recommendations. Brett and other family members had met with McSweeny that morning, and Brett came away with the impression that the FAA official was more interested in making excuses than in being aggressive about the rudder problem.
Brett said he regretted that the NTSB had been unable to solve the Colorado Springs mystery eight years earlier. If they had solved it, he said, “Joan would be alive today.”
Upstairs in the FAA office, McSweeny stubbornly refused to give the NTSB credit. He said his agency would take further action about the 737, but he said it was not because of anything the NTSB had done. He said the FAA would call for faster minimum speeds to ensure that 737s did not fly slower than the crossover point, but he insisted, “We’re doing that because of the unexplained MetroJet incident. It is not a response to this meeting.”
When Haueter returned to the NTSB office at L’Enfant Plaza, everyone was glum. They were angry about Black’s and Hall’s comments. The board members were backing away from the report they had just approved. “The report was adopted unscathed, but it felt like cold water was thrown on it,” Haueter said.
To perk up the troops, he went downstairs to the L’Enfant Plaza mall and bought four bottles of champagne and some plastic glasses. He summoned the Flight 427 team to the conference room.
They reminisced about the investigation. Malcolm Brenner told the group that Haueter must be blessed with some kind of superhuman hormone that kept him going when others were ready to quit. Someone else proposed a toast to Eastwind pilot Brian Bishop
, who had survived a rudder reversal, saved fifty-five lives, and given the NTSB key evidence about what was wrong in the 737.
“To Captain Bishop,” one of the investigators said, and they all clinked their plastic cups together.
EPILOGUE
With the NTSB investigation complete, lawyers for USAir, Boeing, and the families quickened the pace of their settlement talks. The companies were eager to settle with all families before the Cook County trial, scheduled to begin in November 1999.
Two years earlier, USAir’s insurance company had offered Brett $2 million to settle. The company told Demetrio that it was a reasonable offer because that’s what the company had paid other people in similar circumstances. Brett didn’t think $2 million was enough. He said he wanted to go to court.
To reach a settlement amount for Joan, both sides had hired economists and accountants. They had estimated her lifetime earnings if she had not been killed in the crash, as well as the cost for Brett to hire someone else to perform her household chores. The economists then subtracted the “terminated consumption”—the amount Joan would have spent each year on clothes, food, and so on. The calculations were all part of the painful but necessary process of setting a price on Joan’s life.
There was no agreement on the numbers. The economist hired by Brett’s lawyers estimated his total loss from Joan’s death at $1.6 million to $1.8 million. An economist hired by USAir estimated the loss at $1.4 million, while one hired by Boeing came in at $833,000.
One reason for the disparity was that the parties disagreed on how long Joan would have worked before retiring. The economist hired by Brett’s firm assumed 31 years after the crash, USAir used 29.5 years, and Boeing assumed 28.5. Also, Brett’s economist came up with a higher value for Joan’s household chores. For 1999, for example, he said the chores were worth $10,974. USAir’s estimate was $9,993, while Boeing’s was $7,011.
Why such a range? The economists used different sources for their calculations and applied various factors to adjust them for the future. Their assumptions usually benefited their client’s interests. In general, the economist used by Brett’s lawyer relied on more generous assumptions, while the USAir and Boeing economists used more conservative figures.
The numbers provided a starting point for the settlement talks. In 1998, a year after Brett rejected the $2 million offer, his lawyer, Mike Demetrio, had made a counteroffer to USAir and Boeing, asking for $5 million. Demetrio said that figure reflected the $1.8 million estimate from his economist, plus a sizable amount for Brett’s “loss of society,” the legal term for the loss of love and companionship when a spouse dies. There also was a “significant premium” to account for the long delay since the 1994 crash, Demetrio said.
But USAir and Boeing couldn’t respond because the companies were too busy fighting each other about how much each should pay. At some depositions, the Boeing and USAir lawyers were “screaming at each other at the top of their lungs,” Demetrio said. “It was like watching my third-grader on the playground.”
In February 1999—about one month before the NTSB meeting—Boeing and USAir lawyers put aside their feud and floated the possibility of a $3 million settlement. But Brett again said it was too low. The case was headed for trial.
He viewed the trial as his revenge against the companies. He said he wanted “to stick it to them financially” and embarrass them in court. The USAir and Boeing executives would get a public grilling from Demetrio and other lawyers. For weeks, the companies would be battered by the bad publicity.
As the trial date neared, both sides knew there would be last-minute settlement talks. That was the nature of crash lawsuits. The parties often settled only a few hours before the trial was to start. There were five cases left in Cook County, including Brett’s. They were scheduled to be tried together.
The lawyers had put together powerful exhibits to sway the jury and create public relations problems for Boeing and USAir. The biggest was a full-size, fully functional 737 tail. It was three stories high and painted in USAir’s colors. The lawyers planned to put it outside the courthouse and demonstrate a rudder reversal in full view of the public and the news media. For Boeing and USAir, that would be a public relations nightmare.
Demetrio and the other plaintiff’s attorneys had another powerful prop: a four-foot-long replica of a USAir 737 with a removable top. Demetrio was going to lift the top off and show jurors the inside. He planned to say: “This was where Joan Van Bortel was sitting.”
Negotiations began Monday, November 1, two days before the trial was supposed to start. By the evening of November 2, USAir and Boeing had come up with a new offer for Brett: $6 million. It was double their last offer and $1 million more than Brett’s request a year earlier.
Demetrio called his client shortly before 5 P.M. “We think it’s a good offer,” he said.
“Do I have time to think about this?” Brett asked.
Demetrio said he needed an answer that night.
Sitting in his office in Oak Brook, a Chicago suburb, Brett pondered his options. He had wanted a trial to publicly embarrass Boeing and USAir and force them to be more responsible with safety issues in the future. He felt that Boeing was largely responsible for the crash, that the company knew about the rudder problem after the Colorado Springs accident but did nothing to correct it. Brett believed the company had rolled the dice with people’s lives rather than paying to fix the planes. He also blamed USAir for allowing the plane to have dirty hydraulic fluid, which he believed had contributed to the crash.
On the other hand, Brett wanted to start a foundation named after Joan to pay for scholarships. The money would allow him to start it immediately. Six million dollars was triple the original offer, and Demetrio said it was high for a victim with no children. If Brett went to trial, he would be taking a big risk. He might get less money, and he might not see it for years because of appeals.
Or the trial might give him a lot more.
Time was of the essence. Joan’s father had died recently, and her mother was getting older. Brett wanted Joan’s mother to know that the scholarship foundation was going to be a reality. So he called her at home in Melrose, Iowa, and asked her opinion. She said she was comfortable with Brett making the decision.
After he hung up, Brett came up with a novel way to decide.
Fate had put Joan on Flight 427, so it might as well be fate that decided whether he should settle. He would flip a coin. Maybe God or Joan’s hand would decide which way it landed.
He reached into a drawer where he kept his spare change and grabbed a quarter. It was from 1987, which seemed appropriate because that was the year he and Joan had started dating. Heads he would go to trial. Tails he would settle.
He flipped the coin and was sure it would come up heads. As it tumbled through the air, he thought about the trial and what it would be like. The quarter landed on the carpet.
Tails.
It was time to settle.
He took a long walk and then called Demetrio from his cell phone. He wanted to be sure a settlement wouldn’t prevent him from writing a book about his experiences. Would there be a gag order?
No, Demetrio assured him. Brett was free to talk.
“Let’s end it,” Brett said.
USAir Flight 427 changed aviation forever.
At the NTSB’s urging, the FAA conducted an unprecedented study of the 737 rudder system. An independent panel of hydraulic engineers and flight control experts spent a year studying the valve, flying 737 simulators and analyzing extreme failures that were not fully explored in the Flight 427 investigation.
In its final report, the panel agreed with the NTSB and warned that the 737 rudder system was susceptible to many failures and jams that could be catastrophic. The group recommended better training for 737 pilots and, in the long term, a complete redesign of the plane’s rudder system.
As a result of the report, the FAA and Boeing announced in September 2000 that the unique valve-within-a-valve
rudder system on all 737s would be replaced by a two-valve system, similar to the one used on other planes. The announcement marked a surprising and dramatic change for Boeing and the FAA. Both had insisted for years that the redesign was unnecessary.
Boeing said it would pay the entire cost of the new rudder system, estimated to be more than $240 million. The company said the new system should be installed in all 737s by 2007.
In the meantime, all 737s have been equipped with improved valves that cannot reverse. The planes also have better yaw damper couplers (the computers that command small adjustments to the rudder) and pressure limiters (devices that limit how far a rudder will move). Pilots have been alerted to the crossover point and have been trained to identify and recover from rudder problems.
After years of complaints from the NTSB, the FAA mandated that airlines upgrade flight data recorders to take additional measurements such as rudder pedal position, a change that should make it easier for investigators to determine the cause of future crashes. Instead of the thirteen parameters recorded on the USAir plane, they now must have at least seventeen.
Tom McSweeny, the FAA official who was criticized for being soft on Boeing, left the FAA in the fall of 2001. He is now director of international safety and regulatory affairs for Boeing.
USAir changed its name to USAirways in early 1997 after former United Airlines head Stephen Wolf became chairman. One of Wolf’s first priorities was a new image that has helped erase the memories of the airline’s five crashes. USAirways repainted its fleet, announced plans to buy new Airbus planes (the airline said the 737 problems were not a factor in the decision), and improved amenities for frequent travelers. A plan to merge with United Airlines fizzled in 2001, so USAir once again talked about consolidating and cutting costs. Its future was unclear as this book went to press.