As they debated the wording of the report, Black and Francis were particularly concerned about one of its findings, which lambasted the FAA for certifying the 737 rudder system. The finding said that the 737 would not have been certified if the FAA had insisted on “a high level of safety.”
If that was true, the board members said, the NTSB should be calling for the entire 737 fleet to be grounded—which would be viewed as a ridiculous request. The plane had 92 million flight hours and one of the lowest crash rates of any transport jet.
Black and Francis also complained that the report’s recommendations for the rudder system were too specific, reading like a mandate for Boeing to split the system into two separate valves. They said the NTSB should not tell Boeing or the FAA how to design airplanes. The board should recommend broad principles and leave the details to the experts. Black kept invoking a philosophy used by physicians: “Do no harm.”
Haueter and Loeb insisted that they did not want to ground the plane, which would put entire airlines out of business and wreak havoc with the world’s economy. But they argued that the rudder system needed to be redesigned because a single failure could cripple the plane. Indeed, two years earlier, the five board members had unanimously approved a safety recommendation letter that said the 737 was not as safe as other planes.
While the other board members debated the wording, Hall began to strategize how he could get a unanimous vote. He believed a 4-0 decision was critical in order to maintain the board’s credibility on such a touchy issue. Hall was comfortable with the strong wording in Loeb and Haueter’s report, but he was perfectly willing to tone it down to get a 4-0 vote.
He was in a bind. If he kept Loeb’s strong language but ended up with a 2-2 deadlock, the whole four-year investigation would go down the drain. The FAA and Boeing might end up doing nothing to fix the plane. On the other hand, if the report was weakened too much, there was a risk that Loeb would get angry and publicly criticize the board. Loeb had never explicitly made such a threat, but he didn’t have to. He was about to retire and had nothing to lose. He was well regarded among aviation reporters and a complaint from him that the board wasn’t tough enough would surely make front-page headlines.
The deliberations showed the NTSB as a dysfunctional family. Francis rarely spoke with other board members or with the investigators, yet he complained that Loeb wouldn’t permit his underlings to speak freely. But Loeb and the staff complained that Francis was aloof and had not spent much time studying the accident. Likewise, relations between Black and Loeb were strained. Black felt that Loeb was too abrasive and that he stifled discussion of ideas.
Hall appointed his assistant, Deb Smith, to act as a peace negotiator. She shuttled back and forth from Francis to Black to Loeb, trying to broker a compromise. Black and Francis had tremendous leverage in getting the changes they wanted. Francis, using his special counsel, Denise Daniels, as his own peace negotiator, sent a lengthy memo that detailed his concerns. He said he would vote against the entire report unless the changes were made. His complaint was primarily about tone. He wanted the report softened so it did not sound so absolute that the rudder had reversed.
There were lengthy debates about a single word. The draft report had said the 737 needed a rudder system that was “truly redundant.” Loeb and Haueter had added “truly” to strengthen the sentence so McSweeny, the FAA safety official, would not have any wiggle room. They were afraid if they simply said the valve was not redundant, McSweeny would retort that it was redundant. By adding “truly,” they gave the sentence more impact.
Black, who was often annoyed by Loeb’s aggressive style, was not about to accept Loeb’s word. Black suggested “reliably redundant,” which ultimately was adopted as the final wording.
The group also debated whether to ask the FAA to establish an independent panel to assess the 737’s rudder system. The panel, which would have representatives from Boeing, the FAA, the NTSB, and academia, would conduct a year-long examination and make recommendations on how the plane could be improved. Loeb regarded that as a waste of time. The NTSB was supposed to be the independent safety agency, he said. There was no need to call in another independent group to validate their work. That just undermined the NTSB’s authority. But Black and Francis liked the idea of an independent panel that would take a broad look at the 737’s problems and make an impartial recommendation. The suggestion for the panel got added to the report.
After exchanging drafts by E-mail, the board members also decided to tone down the probable cause statement. Instead of Loeb and Haueter’s definitive assertion that a rudder reversal had caused the crash, the board members softened it to say the sudden movement by the rudder was “most likely” caused by a jam and reversal.
As the final meeting neared, it appeared that Smith and Daniels had brokered a compromise. But as they walked into the hotel ballroom, they were nervous that the deal might unravel.
The final meeting on Flight 427 was held at the Springfield, Virginia, Hilton on March 23 and 24, 1999. The big room looked like a movie set. Blue lights illuminated the curtains. The board members sat behind a wooden desk like a jury deciding if the 737 was guilty of murder.
Chairman Hall opened the meeting by reading a statement that said the event was part of the Government in the Sunshine Act, which required federal agencies to do their work “in open session.” But in fact, all of the real debate had occurred behind closed doors long before the meeting.
It was one of the biggest days in Haueter’s career, and his wife, Trisha Dedik, had come to watch. Haueter hadn’t slept well the night before the meeting, waking up several times worrying about the outcome. But as he tossed in bed, he couldn’t pin down any single thing that was likely to go wrong.
The ballroom was packed with about three hundred people. Relatives of Flight 427’s passengers sat in a special section, many wearing photos of the victims on buttons or chains around their necks. Brett Van Bortel took a seat in the last row of the family section. He didn’t realize it, but sitting in the row directly behind him were the people he blamed for Joan’s death—top officials from Boeing and USAir.
Brett was looking healthy and confident. It had been four and a half years since the crash, and he had healed as much as anyone could. He was dating again and engrossed in his job at a mutual fund company. He listened attentively as Haueter began his presentation.
“Today, the investigative staff is pleased to present the report on the crash of USAir Flight 427,” Haueter said. He noted that it had been the longest investigation in the safety board’s history.
Over the next several hours, Haueter and his team explained the 737 rudder system and why they believed it had reversed on the USAir, United, and Eastwind planes. They spoke in absolutes, as if there was no doubt about what happened.
“The pilot is surprised and pushes harder—as hard as he can,” Malcolm Brenner said about Flight 427. “But instead, the controls reverse and move the rudder all the way to the left.”
Brenner talked about the risks of the crossover point. He said Emmett, Flight 427’s first officer, discovered “for the first time in his career” that he could not turn the wheel to bring the wings level and stop the plane from rolling out of control. The veteran pilot was helpless as the big 737 began to plummet toward the ground.