The Mystery of Flight 427

by Bill Adair

  Boeing merged with its rival McDonnell Douglas in 1997. One of the biggest challenges for the gargantuan company has been keeping up with demand. Sales of 737s remained strong and were unaffected by the controversy over the rudder. In 2000 Boeing produced more than twice as many 737s as in 1994, the year of the crash.

  The painful experiences of the families of Flight 427 and other crashes prompted Congress to pass the Aviation Disaster Family Assistance Act, which requires airlines to have detailed plans for responding to a crash and notifying family members. An airline must notify the next of kin as soon as it verifies that the passenger was aboard the plane—regardless of whether other names have been confirmed, and the airline must consult with families about plans for human remains and personal effects. Also, the law says attorneys cannot make unsolicited contact with families until at least thirty days after an accident.

  Under the new law, the NTSB is designated as the main federal agency to help families after an aviation disaster. Many safety board investigators, including Haueter, did not want their agency to take on that responsibility because they believed it conflicted with the safety board’s investigative mission. But Chairman Jim Hall said it was consistent with the government’s role to help people in need. Since the passage of the act, airlines and the NTSB have been praised for their treatment of families.

  In late 2000, Tom Haueter was promoted to deputy director of aviation safety, the second-highest aviation job in the NTSB. He says he is confident that his team solved the mystery of Flight 427, although it’s possible that the 737 rudder system may have other failure modes that haven’t been found. “The big lesson is to keep pushing,” he says. “In 585 [the Colorado Springs case], we ran out of data and quit. In 427, we didn’t quit.”

  In the summer of 2001 the NTSB released a revised report on United Airlines Flight 585, the Colorado Springs crash. It incorporated the findings of the Flight 427 investigation and the new conclusion that the United plane most likely had a rudder reversal. The words “FOR UNDETERMINED REASONS” no longer appear on the cover.

  Haueter still flies in 737s on business trips, but his constant talk of rudder problems has frightened his wife, Trisha, to the point that when they go on vacation, she insists on flying in a different type of plane.

  Jean McGrew retired from Boeing in 2000. He says the crash investigation took a heavy toll on him and was a big factor in his decision to retire. Always blunt about his feelings, he says he is still convinced the pilots caused the crash.

  However, McGrew says he is glad the 737’s unique rudder valve is being replaced. “It was not as good as it should have been,” he says. “It could have been more fail-safe than it was.”

  He has strong feelings about the NTSB and how it was run by politicians: “I think they ought to take the politicians and get rid of them.”

  John Cox was promoted to fly the Airbus A320 for USAirways and in 2001 was named chairman of ALPA’s Executive Air Safety Committee, the union’s top safety job. During the USAir investigation, a fellow pilot sent him a book with this inscription: “John, there are people alive today that otherwise would not be except for your work in safety, and I thank you for that.”

  On September 9, 2000, the day after the sixth anniversary of the crash, Brett Van Bortel got engaged to Victoria Hartz, a woman he had been dating for several years. They were married in July 2001.

  His lawyers received $1.5 million, which was 25 percent of his settlement. After other expenses were deducted, Brett ended up with $4.18 million. He is using $1 million for the Joan Lahart-Van Bortel Memorial Scholarship Fund. Each year, it provides a four-year scholarship for a young woman from Joan’s home county in Iowa to attend college. Brett also used some of his settlement to take Joan’s mother and brother to Ireland.

  Brett says he has healed as well as anyone can. Coping with the crash “is something that never gets better, it just recedes further in the past.”

  As I completed interviews for this book in 2001, many people at the NTSB wanted to take credit for the success of the Flight 427 investigation. There were so many conflicting claims that it took me several days to sort them out. Ultimately, I decided it doesn’t matter who came up with the idea for the independent engineering panel or who devised the phrase “reliably redundant.” The truth is that the Flight 427 investigation was an extraordinary team effort. If it weren’t for the odd mix of characters and brilliance and pure good luck, the case might still be open.

  Haueter’s quiet persistence kept the investigation plodding along when some at the safety board wanted him to give up. His friendly, low-key style allowed a healthy exchange of ideas. His friend Greg Phillips, the systems group leader, was an important voice of caution. Phillips kept the NTSB from rushing to judgment and blaming the valve when there was insufficient proof.

  Loeb, the aggressive manager, provided an important spark when the investigation reached its lowest point. He cleared the way for the first batch of safety recommendations and became the forceful advocate Haueter needed at the end.

  Chairman Hall’s lack of technical experience and his country bumpkin persona often frustrated the investigators. But his outsider perspective led to the most important breakthrough. It was Hall’s idea to create a panel of the Greatest Minds in Hydraulics, a suggestion that some investigators—including Haueter—opposed. The panel proposed the thermal shock test, which became the turning point of the investigation.

  Board members George Black and Bob Francis also provided an important perspective, toning down a report that was stronger than the facts justified. They made sure it was based on solid ground.

  The NTSB party system has often been criticized for supposedly allowing companies to manipulate an investigation. But in this case, it worked marvelously. The key discovery in the investigation—that the valve could reverse—was made not by someone at the NTSB but by an engineer at Boeing. The company provided immeasurable technical experience to the probe, as well as millions of dollars in tests that the tiny safety board could never have afforded. The constant fighting between Boeing and ALPA crystallized the issues for the safety board and ensured that every theory was considered.

  During the six years I worked on this book, I heard a lot of criticism of the NTSB. I approached the investigation with an open mind. I considered the possibility that the party system was flawed or that the NTSB was a puppet that could be controlled by a powerful corporation such as Boeing. But I found just the opposite. The party system led to important breakthroughs, and Haueter and his investigators were not cowed by the mighty Boeing Company. I also believe that the NTSB’s messy internal fights led to a more solid report and that the tension between the NTSB and the FAA creates a healthy check and balance.

  In the case of Flight 427, the system worked.

  ILLUSTRATIONS

  The View from the Cockpit

  Using information from the flight data recorder and the radar track, photographer Bill Serne re-created the final 28 seconds of Flight 427. He shot the pictures from a helicopter matching the altitude and pitch to show what the pilots would have seen out their window as the jet spiraled down. A note about altitude: The plane crashed into a hill that was about 1,300 feet high, so impact occurred at 1,300 feet, not zero.

  (Photographs copyright 1999 St. Petersburg Times)

  28 seconds to impact, altitude 6,000 feet.

  “Oh, yeah, I see zuh Jetstream.”

  “Sheeez.”

  15 seconds to impact, altitude 5,800 feet.

  “What the hell is this?”

  12 seconds to impact, altitude 5,000 feet.

  “Oh God… Oh God.”

  2 seconds to impact, altitude 1,800 feet.

  “God!”

  1 second to impact, altitude 1,500 feet.

  “Noooo…”

  Joan Van Bortel. She left for the airport so late that coworkers thought she would miss her flight.

  (Photo courtesy of Brett Van Bortel)

  Brett and Joan Van Bor
tel at a company party on September 2, 1994, six days before the crash. Joan had lots of ambition. She wanted to be the highest-ranking woman at Akzo Nobel.

  (Photo courtesy of Brett Van Bortel)

  The grisly scene on the hill. Investigators had to sift through dirt and vegetation to find the tiny pieces of wreckage.

  (Photo courtesy of the FAA)

  Plastic suits. Investigators had to wear protective clothing and be decontaminated with a bleach solution.

  (Photo courtesy of the FAA)

  The scene in the Pittsburgh hangar. The wreckage was laid out in the shape of an airplane.

  (Photo courtesy of the FAA)

  An impossible jigsaw puzzle. Investigators found a few large pieces of the wing and fuselage, but most were no bigger than a car door.

  (Photo courtesy of the FAA)

  NTSB chairman Jim Hall amid the wreckage.

  (Photo courtesy of the FAA)

  A piece of Ship 513s fuselage. The plane virtually disintegrated when it struck the hill.

  (Photo courtesy of the FAA)

  The plane’s battered logbook, recovered from the wreckage. The log showed that Ship 513 had no significant mechanical problems before the flight.

  (Photo courtesy of the FAA)

  The mangled flight data recorder. It took only thirteen measurements and could not answer the fundamental question of the investigation: Did man or machine cause the crash?

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  Tom Haueter. He brought a refreshing dose of Midwestern charm to the investigation. “Holy mackerel!” he frequently exclaimed.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  Jean McGrew. Boeing’s chief engineer for the 737 believed the pilots were startled and caused the crash.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  Greg Phillips holding the unique rudder valve from the USAir plane. He was the most cautious voice at the NTSB. While other investigators were convinced there was a malfunction, Phillips was still unsure.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  A ghost ride in Boeing’s M-Cab flight simulator. M-Cab rides allowed investigators to re-create the final seconds of Flight 427 and feel the same bumps and twists that the pilots did.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  Roxie Laybourne. The world’s expert on feather identification was called in to determine if a bird caused the crash.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  John Cox. The USAir pilot believed there was “a gremlin” in the plane that made the rudder malfunction.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  Brett Van Bortel at the crash site on the first anniversary. He looked up at the sky as a USAir 737 passed overhead.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  Mementos in the woods. This tree, photographed on the one-year anniversary, still bears scars from the crash.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  The investigators talk with the press before the flight tests. From left, Bud Laynor, Mike Benson, Tom Haueter, and Tom Jacky.

  (Photo courtesy of the FAA)

  The wake turbulence test. Pilots flew the USAir 737 through the wakes of another plane to see if turbulence played a role in the crash.

  (Photo courtesy of the FAA)

  Cox (visible in the cockpit) flies the USAir 737 during the tests. A T-33 chase plane flies beside the 737 to take photos.

  (Photo courtesy of the FAA)

  Haueter in his Stearman biplane. To get a break from the pressures of the investigation, he went flying.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  Testing the fat guy theory in a Boeing hangar. The investigators wondered if an overweight passenger had stepped through the floor onto a rudder cable.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  Tom Haueter and his wife, Trisha Dedik. She grew frustrated as the investigation consumed her husband and interrupted their life together.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  A memorial to the crash. The names of Flight 427’s 132 passengers are etched in granite at the Sewickley Cemetery outside Pittsburgh.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  Brian Bishop. The Eastwind Airlines pilot experienced a rudder incident that was eerily similar to that of Flight 427.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  Malcolm Brenner. The NTSB human-performance expert studied the pilots’ grunts and cursing for clues about what happened.

  (Photo by Bill Serne; copyright 1999 St. Petersburg Times)

  GLOSSARY

  ailerons Panels on the wings that control the roll of the plane and allow it to bank to the right or left.

  ALPA The Air Line Pilots Association, a labor union.

  control column The “stick” in the cockpit that pilots use to make the plane climb and descend. On top of the control column is the wheel, which is used to control the roll of the plane.

  crossover point The critical airspeed at which a full swing by the 737’s rudder cannot be counteracted by the ailerons. When a plane has a rudder hardover while flying slower than the crossover point, the pilot must speed up to regain control.

  CVR Cockpit voice recorder. Also known as a “black box,” it records sounds and pilot conversations that help investigators determine what caused a crash.

  flaps Movable panels on the wings that provide extra lift for a plane at slower airspeeds.

  fly-by-wire A computerized system in newer airplanes that sends electronic signals to move the flight controls. The Boeing 737 is not a fly-by-wire plane. It has cables that move back and forth to send commands to the flight controls.

  hardover A malfunction that occurs when the rudder or another flight control suddenly moves as far as it can, usually because of a problem with a hydraulic device.

  jump seat A fold-down seat in the cockpit that allows an FAA inspector or a company official to observe the pilots. Most airlines allow their pilots to ride in the jump seat to commute from their home city to their crew base.

  M-Cab The special Boeing flight simulator in Seattle that was used to re-create the crash and test scenarios about what happened.

  party system The NTSB practice of allowing companies and labor unions to take part in an investigation.

  power control unit (PCU) The hydraulic device that moves the rudder or another flight control. The rudder PCU on the 737 is about the size of an upright vacuum cleaner.

  rudder The movable vertical panel on the tail. On the 737, pilots use it primarily when landing in a strong crosswind or on the rare occasion when they have an engine failure.

  servo valve A soda can-size valve inside the PCU. The 737 has a unique version known as a dual concentric servo valve. It has two tubes that slide back and forth. The slides send bursts of hydraulic fluid against a piston that moves the rudder.

  stall The result when a plane no longer has enough air moving over its wings to stay aloft.

  stickshaker A device that rattles the pilots’ control columns to warn them that the plane is about to stall.

  wheel The steering wheel—like device in the cockpit that pilots use to move the ailerons and flight spoilers, the panels on the wings that cause the plane to roll to the left or right. The wheel is on top of the control column.

  windscreen The front window on an airplane, like a windshield on a car.

  yaw damper A device that creates a smoother ride by making hundreds of small adjustments to the rudder during a flight.

  SOURCES

  This book is based on hundreds of hours of interviews that I conducted over six years with the principal characters—Tom Haueter, Brett Van Bortel, John Cox, and Jean M
cGrew. I spent many Saturdays in Haueter’s living room and went flying with him in his Stearman. Likewise, I spent many afternoons in John Cox’s home in St. Petersburg, Florida, where he taught me about airplane systems, rudder valves, and crash investigations. He persuaded USAir to allow me to ride with him in the cockpit for a four-day trip in January 1997, a trip that helped me better understand the life of a pilot. We had a grueling overnight in Boston and one that was not so grueling in San Juan, Puerto Rico.

  I traveled to Seattle three times to interview McGrew and spoke with him by phone on several other occasions. A Boeing public relations official was present for most of those interviews, but McGrew was still candid in expressing his feelings about the NTSB.

  I interviewed Brett Van Bortel in Chicago four times, visited the crash site with him on the first anniversary of the crash, and was with him during the final meeting in Springfield, Virginia. We exchanged E-mail frequently and spoke often by phone.