When people make a great physical effort, they take forced and rapid breaths. When Emmett said, “Aw c’mon, you piece of shit” to the flight-management computer, his breathing was normal. But after the plane was jostled by the wake, he grunted, and his voice showed signs of straining. When Emmett said the word seven seconds later, he said it softly and was not straining. That suggested he was no longer fighting the wheel or rudder pedals. It was easier to turn the wheel at that point because the autopilot had just been switched off. The final time Emmett said “Shit!” he was straining again, probably because he was pulling back on the control column, trying to pull the plane’s nose up as the ground loomed closer.
Brenner thought that the sound analysis disproved Boeing’s allegations that the pilots panicked early. The change in pitch was more gradual, proving that they didn’t panic until well after the wake turbulence. Germano said “427 emergency!” to air traffic controllers seven seconds after the stickshaker went off, which Brenner regarded as a rational, constructive action—to let controllers know the plane was in trouble.
Brenner’s biggest finding involved the grunts.
He put Emmett’s heavy breathing and grunts on a time line and noticed that they perfectly matched the theory of a rudder reversal. They occurred during the crucial three-and-a-half-second period when investigators believed the reversal occurred.
Emmett’s soft grunt at the beginning came four-tenths of a second after the rudder began to reverse, when he would have felt the pedal pushing back against his right foot. He grunted louder about one second later, the time when the rudder pedals would have fully snapped back against his pushing. It was a nearly perfect match that indicated Emmett had been struggling against the rudder pedal but couldn’t stop it from reversing.
It was the best evidence yet that the rudder had reversed.
In January of 1997 Haueter had a difficult time sleeping. Many nights he found himself lying awake in the big four-poster bed that he shared with his wife, worried that another 737 would crash. The FAA had issued a slew of airworthiness directives that mandated changes to the 737 and how it was flown, including many that had been requested by the NTSB, but the agency had not acted on the NTSB recommendation that Haueter considered the most important—fixing the rudder’s power control unit.
It had been two months since Vice President Gore had said Boeing would fix it, but Haueter had seen little action. Where was the urgency? Boeing and the FAA were taking a leisurely pace. The FAA—particularly McSweeny—often sounded like an apologist for Boeing. The FAA had mandated a weekly test for rudder jams, but the test was virtually meaningless. It would tell pilots if the PCU was jammed at that instant, but it didn’t tell whether a PCU would jam in the future. Haueter thought that pilots needed to be warned more clearly about the problems.
It was time to light a fire under the FAA.
If Haueter had been a politician, he would just have held a news conference and spoken his mind. But that was not how the NTSB operated. There were unwritten rules of engagement about how to blast the FAA. It was done discreetly, usually by letter to the FAA administrator, which was conveniently faxed to aviation reporters around the country.
Haueter believed the 737 no longer met federal safety standards. He talked with colleagues about whether he should recommend that the entire 737 fleet be grounded but decided he didn’t have enough evidence for such a drastic step. The plane’s fatal accident rate was low compared with those of other planes—even if the rudder PCU did not meet federal standards. The odds of a jam and a reversal were still remote. Nevertheless, he was worried there might be another crash.
In the letter, he used strong words. Haueter had grown more self-assured in the two and a half years since the crash. He’d been promoted to chief of major investigations, which meant he was now the head of all the big accidents, including the ValuJet crash in Miami and the granddaddy of them all, TWA 800. He was not shy about blasting the FAA and Boeing when he felt he had to. The ten-page letter, signed by Hall and endorsed by the other four board members, laid out Haueter’s case about how the soda can valve on the USAir plane was unique and more prone to reverse. The letter called on the FAA to alert pilots about the potential for a reversal and to speed up the process to fix all PCUs in the fleet. His words were surprisingly frank. He said the 737 was not as safe as other planes because the PCU was vulnerable to a reversal.
To make sure that the message got prominent play, Haueter, Loeb, and public affairs director Peter Goelz held a background briefing with reporters from the New York Times, the Washington Post, and the TV networks. Within hours, the news was spread to millions of viewers.
“Federal air safety experts are now satisfied they know what caused the mystery crash of a USAir Boeing 737,” Dan Rather said a few hours later on the CBS Evening News. “It was the rudder.” Without naming anyone at the safety board, CBS reporter Bob Orr said investigators “believe a malfunction in the Boeing 737’s rudder system rolled the plane into a fatal dive. And they suspect a similar failure caused the crash of a United Airlines 737 in Colorado Springs in 1991.”
NBC anchor Tom Brokaw said, “There may be an answer tonight to questions that for years have perplexed investigators of two deadly plane crashes. That answer is certain to raise new fears about the world’s most widely used airliner, the Boeing 737.”
Haueter watched the NBC report at home and felt tremendous relief. His worries about the plane had been told to the world. He wasn’t holding a secret anymore. Everyone knew what he knew.
In the meantime, Boeing had gone into damage control mode. It faxed a statement to the press that said: “Boeing is and has been working with suppliers on an already aggressive schedule” to fix the rudder system. The changes “will serve to make a safe airplane even safer.”
That had become the 737’s mantra, chanted by people at Boeing, at the airlines, even at the FAA. It was the perfect phrase to put a positive spin on the message. The 737 wasn’t dangerous. They were simply making it better.
Despite heavy news coverage about the NTSB’s letter, there was barely a ripple of reaction from the public. The New York Times reported “a collective shrug of indifference” from passengers. “Travel agents, corporate travel managers and other industry officials said yesterday that most passengers demonstrated unshaken confidence in the overall safety of air travel,” the Times said, “and appear to feel that the Government would have grounded the nation’s fleet of 1,100 737’s if they were truly dangerous.”
Boeing’s deft response minimized the repercussions for the company. Its stock price had not been affected by any of the 737 announcements. Wall Street didn’t seem to notice what the NTSB said. Airlines seemed satisfied that Boeing was fixing any problems that the plane had, and they continued to flood the company with orders for new 737s.
Boeing wanted more tests that would push a 737 to its limit. A Boeing test pilot would fly over the Pacific Ocean and try rudder hardovers and other maneuvers to gather new data about the crossover point. Cox thought the tests were unnecessary and were being done to help Boeing defend itself from lawsuits. Worse, Cox was concerned that there might be an accident, which would lead to the immediate grounding of the entire 737 fleet. He joked that 737s would make good restaurants, which was a good thing because that’s all they would be useful for if a Boeing test pilot dropped one into the Pacific.