Despite the embarrassing mistakes on the Rockne crash, accident reports from the 1930s show that investigators were becoming better at using wreckage, pilot interviews, and witness reports to determine what had happened. With no radar records to track a plane’s flight path, they often relied on witnesses from different towns to create a map of a plane’s final minutes.
Investigators of the thirties used the same basic techniques with wreckage that are used today. When they saw lots of pieces spread over a large area, they knew the plane broke apart in flight. Bent propeller blades told them the engine was operating normally when the plane hit the ground. An open drain valve in an empty gasoline tank meant the plane ran out of fuel. Metallurgists learned to distinguish between parts that broke off in flight because of vibration and those that broke on impact.
As planes got more sophisticated, so did crash investigations. X-ray machines were used to find metal fatigue. Investigators began reassembling wreckage to look for patterns in the broken metal. They even used passenger autopsies to solve cases. Flight data recorders got their start in the 1950s, providing basic information about altitude, airspeed, heading, and vertical acceleration on foil strips. If the recorders managed to survive a crash—and many did not—they could give investigators a rough idea of what had happened. Investigators began enlisting help from airlines, unions, and manufacturers to provide technical expertise, an approach that became known as the party system.
Tension has always existed between accident investigators and the agencies that regulate aviation. The Civil Aeronautics Board, which investigated crashes in the 1950s and 1960s, often got into spats with the Federal Aviation Agency (which became the Federal Aviation Administration in 1967). FAA administrator Elwood R. Quesada frequently angered the investigators by showing up at crash sites and spouting theories about what caused the accident. His behavior violated the post-Rockne rules about not speculating in public. The CAB frequently criticized the FAA for lapses in safety, but FAA officials saw that as a self-serving effort by the watchdog to get more money from Congress.
The NTSB was created in 1966 to consolidate the government’s safety offices. It investigates all types of transportation accidents—aviation, railroad, highway, marine, and pipeline. The 1966 law says the board should find the “cause or probable cause of major transportation accidents and disasters.” That phrase, which dates back to the 1930s, when the Commerce Department was conducting investigations, gives the NTSB some important wiggle room. It is probable cause because Congress believed there would be times when no one would know the absolute truth about why a plane crashed.
In a city of bureaucratic elephants, the NTSB is a mouse. It has only 450 employees and has to mooch off other government agencies in virtually every investigation. It calls the navy when it needs divers, the FBI when it needs bomb experts, and the Armed Forces Institute of Pathology (AFIP) when it needs a coroner.
The NTSB is governed by five political appointees who serve five-year terms. They act as judge and jury after a crash. Investigators such as Haueter are the prosecutors who must convince the board that there is sufficient evidence for the probable cause. But the board often modifies or even rejects the staff recommendation.
The board has little official power, but it still manages to have an impact. When the board determines the cause of a crash, it sends recommendations to the FAA, the airlines, airplane manufacturers, and others. The board may ask for new pilot procedures, changes in training, modifications to an airplane, or all three. The targets of these missives often roll their eyes and sometimes refer to the NTSB as the “Not Too Smart Boys.” But the recommendations get results. More than 80 percent are enacted.
With such a tiny budget, the NTSB has to rely on the party system to get help for its investigations. The parties—airlines, airplane manufacturers, the FAA, and unions representing the pilots and mechanics—are invited to provide expertise. They work side by side with the investigators. Pilots explain sounds on the cockpit voice recorder, FAA officials explain how they tested a plane, and airline mechanics identify wreckage.
Representatives from the parties become the NTSB posse. They help at the crash site, attend the nightly meetings, and are invited to submit their ideas about the crash. The parties also benefit from being part of the team. If the NTSB discovers something wrong with an airplane, the team members from Boeing can make sure it gets fixed quickly. Likewise, if the NTSB finds that an airline has a shoddy maintenance program, the airline can correct the problem before it causes another crash.
Critics say the party system is a dangerous way to run an investigation. They say big companies such as Boeing and the airlines are more interested in protecting themselves from lawsuits and costly safety fixes than in finding the truth. The critics say the companies can overpower the NTSB and divert attention from the true cause. They liken it to a police homicide investigation. If the party system were used after a homicide, the suspected killer would be allowed to work side by side with the police. He would be given access to all the evidence and allowed to steer the detectives to other suspects. Arthur Wolk, a Philadelphia lawyer who represents families of plane crash victims, said once on Larry King Live that the NTSB protects big companies. “We all know that government is nothing more than a vehicle for special interests and Boeing is one of the biggest special interests in this country.”
Haueter liked the party system. Yes, it could be loud and ugly. Each party had its own interests at stake. The pilots union often protected its members, while Boeing defended its planes. The parties often clashed like Republicans and Democrats. But the safety board was well aware of their biases, and investigators were smart enough not to be bamboozled. Haueter felt the system provided healthy checks and balances.
Arguments were a big part of the NTSB culture. Although board members and investigators were careful not to speculate publicly about a crash, there were intense debates behind the locked glass doors at the NTSB offices in L’Enfant Plaza. Rudy Kapustin, a former investigator in charge, remembers having frequent loud arguments with colleague Bud Laynor during their daily commute home to the Maryland suburbs. They would argue nonstop during the thirty-minute drive and then exchange friendly good-byes. When they drove to work the next morning, they would pick up the argument right where they had left off. Two other safety board employees once got into such a heated argument in a conference room that they started slugging each other and had to be pulled apart. “If people watched the way we worked, they would be totally shocked,” Haueter said. “There’s yelling and screaming, but it works. All these major issues come out and they all get addressed.”
The safety board had a near-perfect record at finding the cause of a crash. After all, aviation was a black-and-white science. Engineers knew the exact speed at which a plane lifted off the runway and when it would stall and tumble to the ground. With flight data recorders and cockpit voice recorders, they could do amazing calculations to figure out why a plane crashed. In the NTSB’s thirty-year history, only four major accidents had been unsolved. But one of those—a crash in Colorado Springs in 1991—involved the same type of plane used for Flight 427.
A Boeing 737.
After surveying the horror at the scene, Haueter drove to a USAir office building about ten miles away for his first meeting with the parties and the safety board employees who were taking part in the investigation. He didn’t like the fact that the meeting was held at USAir. He wanted an impartial setting, but the hotel meeting rooms were not yet available and he needed to get started.