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Perspective: The probe that made airlines safer

 
[ CAMERON COTTRILL | Times ]
[ CAMERON COTTRILL | Times ]
Published Sept. 5, 2014

On a Saturday evening a few weeks ago, about a dozen plane crash investigators gathered at a home in Great Falls, Va., a posh Washington suburb. The party was a farewell to a colleague who was moving to Florida and the 20th reunion for the team that solved one of the greatest mysteries in American aviation.

Twenty years ago tomorrow, USAir Flight 427 twisted out of the blue sky over Pittsburgh and crashed into a suburban hill, killing all 132 people on board. The investigation became the longest in the history of the National Transportation Safety Board, and it raised doubts about whether the Boeing 737, the world's most widely used commercial jet, was truly safe.

In conversations over wine and dinner in the living room of team leader Tom Haueter, the investigators reminisced about their detective work: the grisly scene they encountered at the crash site and the difficulty of working in hot biohazard gear. They talked about the crazy leads they pursued and the arguments they had. They recalled how Flight 427 changed aviation, and their lives, forever.

Most NTSB cases are wrapped up in a year. This one took five. They had to sort out competing theories from Boeing officials (pilot error) and the pilots union (mechanical malfunction). The investigators went to extraordinary lengths to figure out what happened. They recreated the flight in simulators to try to experience what the pilots were feeling, and they analyzed the pilots' grunts and the inflections in the way the co-pilot said "s--t" to determine if he had made a fatal mistake.

The data kept pointing toward the rudder. As the years wore on, there were more 737 rudder incidents ranging from minor malfunctions to a scary episode where the pilot of an Eastwind Airlines plane nearly lost control near Richmond, Va. The NTSB ultimately blamed the USAir crash on a sudden movement by the plane's rudder and said it most likely occurred because of a rare reversal by a hydraulic valve. The safety board recommended sweeping changes to the 737's rudder system, which the FAA and Boeing reluctantly implemented.

The fix has worked. There hasn't been a rudder incident since.

"We got this one right," Haueter, now 62 and retired from the NTSB, said after the party. "There was a lot of pushback — and we found the problem."

The long investigation forged strong bonds the way combat does in an Army unit. NTSB investigations are a tricky business because they require substantial help from organizations that inherently have a conflict of interest and often point fingers at each other. But they ultimately come together out of common cause: nobody wants another plane to crash again.

The dinner party guests included the core of a group of people that at one point numbered 100, ranging from Boeing test pilots to the Smithsonian's expert on bird feathers.

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Vikki Anderson, a retired investigator for the Federal Aviation Administration who was honored at Haueter's party because she was moving to Florida, said the Flight 427 team had grown closer than other cases she had worked on. Maybe it was the duration or maybe because the stakes were so high.

"It was worth all the worry, all the infighting, because we haven't had another 737 come out of the sky," she said.

Gathered in Haueter's living room, the team members talked about Flight 427's legacy. Haueter worries that the lessons of the crash are being forgotten.

When it closed the case, the NTSB recommended that airline pilots get better training so they can control a plane that gets jostled by the wake of another jetliner or a sudden malfunction. But Haueter is still concerned that today's pilots are overly reliant on automation.

"They're too complacent," he said.

The party was a reminder that crash investigators are a bunch of worriers. They are always fretting about lapses in safety. Never mind that aviation is a remarkable success story and that the accident rate for airliners has declined to the point that it is infinitesimal. Crash investigators are never satisfied and tend toward fatalism. When they speculate about the next big accident, they go big. The living room consensus: two airliners in a fiery runway collision.

They also think that big data isn't all it's cracked up to be. Data is great, they said, but you need people with experience flying and working on airplanes to make sense of it. The investigators are concerned that the FAA has too many number-crunchers without enough experience with actual airplanes.

That has long been a theme with Haueter, who flies a 1943 Stearman biplane he restored himself. Toward the end of the party, he took his guests to the basement to show his new project: a 1933 Lockheed Altair that he is building from original plans. He held up the rudder, which he had carefully cut from spruce. He's still looking for a place large enough to assemble the wings, which will be 46 feet from tip to tip.

For Haueter, the real story of Flight 427 is one of perseverance.

"The huge lesson," Haueter said, "is that you have to look at all the assumptions of whatever you do in life."

Bill Adair, a former reporter and editor for the Times, is the author of "The Mystery of Flight 427: Inside a Crash Investigation," which is based on 28 Seconds, a series he wrote for the Times in 1999. He is now a professor of journalism and public policy at Duke University.