“As you know,” Gore said, “the investigations into the crashes of Boeing 737s in Colorado Springs and Pittsburgh have not yet been closed. But those investigations have identified improvements that could help eliminate the chance of rudders playing a role in future accidents. These changes can and should be made without delay.”
Brett listened intently. It sounded like the 737 was getting fixed.
“Boeing has developed modifications to the rudders of older 737s that will improve safety,” Gore continued, “and they are going to begin retrofitting those planes, largely at their own expense, without waiting for a government mandate. Under a schedule to be developed by the FAA, these improvements will be made in the next two years. This is a major action: it affects some 2,800 planes worldwide, 1,100 of them here in the United States.”
Tears welled up in Brett’s eyes. It sounded as if the government was actually doing something to prevent another crash. He felt vindicated. He had believed all along that there was some kind of flaw in the rudder system. He felt as though he had reached the end of a long road.
At a news conference later that day, Boeing officials announced the specifics. The company would modify every 737 rudder valve so it could not reverse. A limiter would be installed on the PCU to prevent the rudder from going hardover. And, in a reminder that Boeing still believed the pilots were at fault, the company said it would pay for sensors on the rudder pedals. The next time a pilot stomped on the pedal by mistake, it would show up on the flight data recorder.
Haueter was disappointed that Gore praised Boeing repeatedly and made only a passing mention of the NTSB. Gore made it sound as if Boeing, out of the kindness of its heart, had generously offered to spend $150 million to fix the PCUs. Never mind that the changes were a direct result of the work by him and Phillips!
“We dragged these people kicking and screaming for the last two years, and all of a sudden they are getting all the credit,” Haueter said. “We have just been pounding them and pounding them, and now we don’t exist.”
His boss, Bernard Loeb, shared his anger. “Boeing didn’t do this because their hearts told them to do it. Their lawyers told them to do it,” Loeb said. “They didn’t have a goddamn choice.”
The same thing had happened two months earlier when Boeing made the dramatic discovery about the reversal. Whom did Boeing call then? The FAA. The company acted like the NTSB didn’t matter. Haueter had called Howes, the Boeing coordinator, and hollered at him about the fact that Boeing had not notified the NTSB about the thermal shock finding. Howes had sat through the entire Halloween meeting without saying a word. But he insisted to Haueter that no one at Boeing had told him about it.
Haueter had discovered the downside of being the watchdog. To the public and the news media, NTSB investigators were crusaders for safety who could do no wrong. They were the guys in the white hats who found everybody else’s mistakes. But when given the chance, the groups that the NTSB had attacked welcomed the opportunity to fire a few zingers back. So when Boeing and the FAA announced a safety fix, they rarely gave the NTSB credit.
The Boeing announcement was shrewdly timed. Haueter had been working on a new set of recommendations that called for immediate pilot training about the risk of a hardover. He felt that Boeing was trying to preempt him by announcing the rudder system changes first.
Boeing also managed to steal the thunder from Dateline, the NBC newsmagazine that had been working on a segment about 737 rudders for several months. A Dateline crew had been out to Renton and interviewed several Boeing officials. Boeing made sure that Dateline correspondent Chris Hanson got a chance to ride in M-Cab. Two weeks before Gore’s announcement, rumors circulated through the investigators that Dateline was about to slam Boeing for the rudder problems. The segment was scheduled to air January 19.
But then came Gore’s announcement on January 15, with Boeing saying it would improve the plane. That took the wind out of the Dateline segment, which ended up being a surprisingly positive piece that said the airplane was getting fixed.
22. GRUNTS
Malcolm Brenner, the eccentric NTSB psychologist, had made his name at the safety board by studying a drunken sailor. He and Jim Cash, the sound expert, had done a groundbreaking study of radio tapes of the Exxon Valdez accident that indicated the ship’s captain was drunk. To show he was intoxicated just before the ship ran aground, they counted the number of seconds it took him to say each word. He slurred the phrase “Exxon Valdez,” saying it 24 percent slower right before the accident than he had thirty-three hours earlier.
Speech analysis was still a very new tool for plane crash investigations. For a 1985 Japan Air Lines crash, Japanese investigators measured the pitch of the pilots’ words to calculate when they were affected by stress after a sudden decompression. According to the investigators’ calculations, a calm Japanese male spoke at a frequency of 150 hertz, but they found that the pitch of the captain’s voice got as high as 410 hertz after the pilots heard a bang. The pitch of their voices also indicated the pilots were feeling the effects of hypoxia because they had neglected to don their oxygen masks.
Brenner decided to use the same technique on Flight 427’s tape. The result might settle the debate over the Boeing theory that one of the pilots panicked because of the wake turbulence and slammed his foot on the rudder pedal. Brenner also hoped to look for correlations between the pilots’ grunts and when the rudder moved, which might indicate when they had pushed on the pedals.
Brenner and three outside experts studied the cockpit tape one word at a time. Using Cash’s WAVES program, they counted syllables and measured the pitch and volume of each sentence. Germano had said “four-twenty-seven” seventeen times during the tape, which gave them a consistent phrase to measure. As stress increases, humans raise the pitch of their voices. Anything above 300 hertz is considered screaming, an indication that the person has panicked.
They analyzed the way Germano said it each time. His average pitch was 144 hertz before the plane hit the wake turbulence, but it jumped to 214 hertz the last time he said it, which was about seventeen seconds after the wake turbulence. When they looked at his other comments on a bar graph, they saw a gradual increase in his frequency, which indicated that his stress level had progressively increased until he screamed and panicked at the end. There was no evidence that Germano had become “overaroused” when they hit the wake, as Boeing had suggested. They also found no evidence in Germano’s voice that he was trying to forcibly move the controls during the emergency. That was an important detail because it focused attention on Emmett, who had been the flying pilot on the Chicago-Pittsburgh leg of the trip.
The results were less conclusive about Emmett. Scott Meyer, a navy sound expert, said Emmett’s grunts indicated that he was straining, but it was not clear whether the straining came from pushing his feet on the rudder pedals or moving the wheel with his arms. The sounds of straining stopped once the autopilot was switched off, which allowed Emmett to turn the wheel more easily.
Alfred S. Belan, a sound expert from Russia who had analyzed hundreds of cockpit tapes, used a novel approach to figure out what Emmett did. He analyzed the word “shit.”
Emmett had said the word during a calm moment about twenty minutes before the crash. He was trying to program the plane’s navigational computer, but kept having trouble. “Aw c’mon, you piece of shit!” he said. He said it two more times—once as the plane was starting to point nose down and a final time just before the crash. Belan compared his breathing each time and studied color graphs from Cash’s WAVES program. The graphs turned “shit” into orange lines that looked like a salmon filet, but Belan could look at them and see the difference between a grunt, Emmett’s inhaling, and the word.