Brett says he has healed as well as anyone can. Coping with the crash “is something that never gets better, it just recedes further in the past.”
As I completed interviews for this book in 2001, many people at the NTSB wanted to take credit for the success of the Flight 427 investigation. There were so many conflicting claims that it took me several days to sort them out. Ultimately, I decided it doesn’t matter who came up with the idea for the independent engineering panel or who devised the phrase “reliably redundant.” The truth is that the Flight 427 investigation was an extraordinary team effort. If it weren’t for the odd mix of characters and brilliance and pure good luck, the case might still be open.
Haueter’s quiet persistence kept the investigation plodding along when some at the safety board wanted him to give up. His friendly, low-key style allowed a healthy exchange of ideas. His friend Greg Phillips, the systems group leader, was an important voice of caution. Phillips kept the NTSB from rushing to judgment and blaming the valve when there was insufficient proof.
Loeb, the aggressive manager, provided an important spark when the investigation reached its lowest point. He cleared the way for the first batch of safety recommendations and became the forceful advocate Haueter needed at the end.
Chairman Hall’s lack of technical experience and his country bumpkin persona often frustrated the investigators. But his outsider perspective led to the most important breakthrough. It was Hall’s idea to create a panel of the Greatest Minds in Hydraulics, a suggestion that some investigators—including Haueter—opposed. The panel proposed the thermal shock test, which became the turning point of the investigation.
Board members George Black and Bob Francis also provided an important perspective, toning down a report that was stronger than the facts justified. They made sure it was based on solid ground.
The NTSB party system has often been criticized for supposedly allowing companies to manipulate an investigation. But in this case, it worked marvelously. The key discovery in the investigation—that the valve could reverse—was made not by someone at the NTSB but by an engineer at Boeing. The company provided immeasurable technical experience to the probe, as well as millions of dollars in tests that the tiny safety board could never have afforded. The constant fighting between Boeing and ALPA crystallized the issues for the safety board and ensured that every theory was considered.
During the six years I worked on this book, I heard a lot of criticism of the NTSB. I approached the investigation with an open mind. I considered the possibility that the party system was flawed or that the NTSB was a puppet that could be controlled by a powerful corporation such as Boeing. But I found just the opposite. The party system led to important breakthroughs, and Haueter and his investigators were not cowed by the mighty Boeing Company. I also believe that the NTSB’s messy internal fights led to a more solid report and that the tension between the NTSB and the FAA creates a healthy check and balance.
In the case of Flight 427, the system worked.
ILLUSTRATIONS
Using information from the flight data recorder and the radar track, photographer Bill Serne re-created the final 28 seconds of Flight 427. He shot the pictures from a helicopter matching the altitude and pitch to show what the pilots would have seen out their window as the jet spiraled down. A note about altitude: The plane crashed into a hill that was about 1,300 feet high, so impact occurred at 1,300 feet, not zero.
