Crider, a goateed former McDonnell Douglas engineer who was considered a genius with flight data, used so much jargon in his presentation that many people in the audience had no idea what he was saying. But they understood when he summarized the 737 incidents by saying, “A rudder reversal scenario will match all three events.” In the audience, Boeing engineers could only listen and bite their lips. They had no opportunity for rebuttal. This was the NTSB’s show.
Smith and Daniels sat behind the board members wondering if their compromise would fall apart. But as the board questioned Haueter and his staff, there were no hints of any disagreements. As the session stretched into late afternoon, Hall decided to adjourn and resume the following day, although many NTSB staff members wanted to wrap it up that evening.
The next morning, Haueter was feeling confident as he drove his Toyota 4-Runner to the hotel. “Everything we wanted to say is now out there,” he said. “I feel pretty good about that.” But as he pulled into the hotel parking lot, Haueter could see that his message about the 737 was not getting the attention he had hoped it would. There were only two TV trucks in the lot. Many network crews had been diverted to the Pentagon because U.S. planes had begun bombing Yugoslavia a day earlier. Hall’s decision to extend the meeting to a second day also diluted the impact, because reporters had to write two incremental stories instead of a single, more powerful account. In many newspapers the 737 decision would be relegated to a short story buried inside.
When Hall reconvened the meeting, board members asked the investigators a few more questions. The questions indicated that they had no major disagreements with the report.
Hall then read the conclusions, the thirty-four findings that built the case for the probable cause. The entire room—the Boeing engineers, the USAir officials, the reporters, Brett and the other family members, Haueter and his staff—had waited nearly five years for this moment.
The USAir Flight 427 flight crew was properly certificated and qualified…. No evidence indicated any preexisting medical or behavioral conditions that might have adversely affected the flight crew’s performance.
The first set of conclusions dealt with what had not happened, to show that the NTSB had ruled out bombs, birds, and a midair collision. The conclusions were designed to satisfy the conspiracy theorists who still believed someone had blown up the plane.
USAir flight 427 did not experience an in-flight fire, bomb, explosion or structural failure.
Hall moved on to the findings that built the case for the valve reversal. He read Conclusion No. 8, which even Boeing could support:
About 1903:00, USAir flight 427’s rudder deflected rapidly to the left and reached its left aerodynamic blowdown limit shortly thereafter.
The next finding ruled out pilot error. All of Boeing’s lobbying—the hours and hours of phone calls, the visits from company executives, the “Boeing Contribution,” and all the rides in M-Cab—had failed to persuade the safety board.
Analysis of the human performance data, including operational factors, does not support a scenario in which the flight crew of USAir Flight 427 applied and held a full left rudder input until ground impact more than 20 seconds later.
Hall switched gears and read several conclusions about the Colorado Springs crash. It was an extraordinary moment. The board was reopening the eight-year-old investigation and declaring that it had solved the mystery.
Analysis of the CVR, Safety Board computer simulation, and human performance data, including operational factors, from the United Flight 585 accident shows that they were consistent with a rudder reversal.
When Hall got to the conclusion that blamed the Colorado Springs crash on a reversal, the families broke into applause. But Hall admonished them, “Please, no demonstrations.”
He then read the probable cause statement for the USAir crash—four and half years of investigation boiled down to two sentences:
The probable cause of the USAir Flight 427 accident was a loss of control of the airplane resulting from the movement of the rudder surface to its blowdown limit. The rudder surface most likely deflected in a direction opposite to that commanded by the pilots as a result of a jam of the main rudder power control unit servo valve secondary slide to the servo valve housing offset from its neutral position and overtravel of the primary slide.
Translation: The rudder probably reversed. The fault was with the airplane, not the pilots.
“Any comment or discussion?” Hall asked, but no one replied. “If not, do I hear a motion that the findings and probable cause be adopted?”
Hammerschmidt made the motion and Francis made the second.
“Seconded,” Hall said. “All in favor, please signify by saying ‘aye.’”
“Aye.”
“Aye.”
“Aye.”
“Aye.”
“The findings and probable cause are unanimously adopted by the National Transportation Safety Board,” Hall said.
Behind him, Smith grinned at Daniels and raised her eyebrows in relief.
In the audience, some family members wept. Others choked back their tears.
Hall invited the board members each to make a final statement. Francis spoke of the importance of flight data recorders. Hammerschmidt said the investigation provided valuable research on wake turbulence. Black said it had been a frustrating experience.
“We engineers normally like to base our decisions on hard, cold facts—measurable things, things we can lay our hands on,” he said. “And while there is much evidence in these accidents, the vast majority of it is not hard, cold evidence.” He said he and his family often flew 737s and that the plane had “a good, documented safe history. There’s an awful lot of successful flights out there.”
As Black left the stage, he told reporters he had misgivings about the case. “I damn near voted against it,” he said. “This is a circumstantial case.”
Hall, renowned for blasting the FAA and Boeing, was uncharacteristically muted. He told reporters that he flew 737s every week, an endorsement of their safety. His only strong comments dealt with the FAA’s sluggishness on flight data recorders. He said little about the rudder. (He later said he was subdued because he did not want to anger the FAA before it began the 737 engineering study.)
After the meeting, Boeing officials held a news conference in the only meeting room they could find in the small hotel—the bar. The company took a conciliatory approach on the 737 report, and no longer pushed the pilot-error theory.
“We respect the board’s opinion,” said Charlie Higgins, Boeing’s vice president for airplane safety. He said new rudder valves being installed in 737s “completely eliminate any possibility of a reversal.”
The company will “do everything we can to look at the 737 rudder system and see if there is anything that can be improved,” he said. Higgins looked to the back of the room where several family members stood, and acknowledged their loss.
“I’d like to sincerely offer our condolences to the families,” he said. “It’s small consolation to them, but I believe this accident has improved aviation.”
Out in the hallway Brett said he felt vindicated.
“Pretty hard-hitting,” he said to his lawyer, Mike Demetrio.
“I agree,” Demetrio said. “They took the approach that the plane was deficient from Day One.”
Demetrio said some people were worried that the board would cave to pressure from Boeing, but that didn’t happen. “Today, I think the taxpayers got their money’s worth from the federal government,” he said.