17 Crash Rulings Win Praise For Ntsb And Its Chairman

SPRINGFIELD, Va. - A few minutes after the longest aviation crash probe in history ended here, National Transportation Safety Board Chairman Jim Hall strolled over to greet family members of people killed in Boeing 737 crashes that were unsolved until yesterday.

"I have nothing but admiration and praise for Jim Hall and the NTSB," said Carolyn Worrell, of Roanoke, Va. "They notified us at every turn; they've made every effort to let us have access; they've been more than understanding."

Worrell's 61-year-old husband, DeWitt Worrell, a carpet-company executive, was one of the 132 people killed in the Sept. 8, 1994, crash of USAir Flight 427 near Pittsburgh.

Yesterday, Carolyn Worrell, her daughter, Mindy, and about 100 other relatives of crash victims sat up front in a hotel ballroom packed with aviation officials and reporters. They applauded when the safety board ruled that rudder malfunctions caused the crash in Pittsburgh as well as a similar 1991 crash of a United Airlines jet at Colorado Springs, which claimed 25 lives.

Both crashes involved Boeing 737s, the most widely used jetliner in the world. Resisting intense lobbying by Boeing, the safety board rejected the company's contention that pilot error caused the crash in Pittsburgh and that a freak gust of wind knocked down the 737 in Colorado Springs.

The board went further, explicitly spelling out its concern in 34 findings and 10 new safety recommendations pointing to dangerous rudder malfunctions that can still occur on 737s. It called on the Federal Aviation Administration and Boeing to take several steps to address that hazard, including looking into a major redesign of the rudder system.

"I'm very pleased the board's wording was so on target and was as powerful as it was," said Gail Dunham, president of the National Air Disaster Alliance & Foundation, a passenger advocacy group. "The truth shouldn't surprise us. This is the United States of America. But it has taken eight years to get to the truth."

The board's probable-cause rulings could hasten the settlement of about 20 remaining civil lawsuits against Boeing and USAir, filed by the relatives of Flight 427 victims. More than 100 similar suits already have been settled.

Chairman Hall brought changes

Traditionally, safety board investigations culminate a year or two after a crash in a Washington, D.C., office building where the NTSB occupies parts of four floors. Usually, few outside of industry and government officials with a direct stake in the board's findings and recommendations show up.

But much has changed since Hall, a folksy lawyer and career political appointee from Tennessee, was named chairman of the safety board in June 1994. And the outcome of the Pittsburgh crash probe here yesterday could signal the start of a new way of doing business for the U.S. aviation safety community.

Much depends on whether Boeing and the FAA ultimately embrace, or reject, the safety board's recommendations. The NTSB has no enforcement powers and can only suggest safety improvements. The FAA has no specific deadline by which to make recommended changes.

Yesterday, representatives of Boeing and the FAA insisted the 737 rudder system is safe and said they remain unconvinced of the need for further safety measures beyond changes made in recent years.

"The 737 is absolutely safe," said Boeing Vice President Charlie Higgins. "My wife and family fly on it. I fly on it. What we've done to date, we think, takes care of all the problems we know about."

Still, several factors that influenced the safety board's investigation could yet come to bear on Boeing and the FAA. They include:

-- Families. Without any public hearings, the safety board ruled in 1992 that it couldn't solve the Colorado Springs crash. But after the crash in Pittsburgh, families formed a support group that - with Hall's encouragement - became a consistent presence in the investigation.

-- News coverage. The Pittsburgh crash took place in a densely populated region and drew intense media attention. Later coverage of other disasters, such as the fiery crash of a ValuJet DC-9 in the Florida Everglades and the midair explosion of a TWA Boeing 747 off Long Island, New York, both in 1996, highlighted growing tensions between the NTSB and the FAA in overseeing the aviation industry.

-- Technology. NTSB investigators methodically derived a plausible scenario on how a specific type of rudder malfunction, called a reversal, caused the crashes in Pittsburgh and Colorado Springs. To do so, they used an innovative laboratory test, designed by a panel of independent experts assembled by Hall, and computer modeling techniques unavailable in the early 1990s,

-- Media savvy. At this week's hearing, NTSB staffers used vivid computer simulations and clear explanations by well-rehearsed experts to demystify technical material and make a persuasive case about the ongoing hazards posed by the 737 rudder system. Animated simulations of two crashes and a near-crash linked to rudder reversals were swiftly posted on the NTSB's Web site: www.ntsb.gov.

"I think there is a real passion among safety board investigators for remedying this before another crash happens," said aviation consultant James Burnett, a former NTSB chairman. "That's the reason the safety board has laid out for the American public the problems with the 737."

`Party system' of investigation

Part of that drive perhaps was borne of frustration over the board's struggle to manage a "party system" investigation in which Boeing, USAir and the Air Line Pilots Association assumed hands-on roles, with each party attempting to steer the inquiry to protect its own interests.

By the time the investigation had plodded into a fourth year, the safety board's veteran aviation staff had become convinced that the 737 rudder was at fault.

After several times postponing a meeting to determine a probable cause for the Pittsburgh crash, Hall last fall set the date for this week's meeting and stubbornly rejected requests to delay it again.

Then, Hall set out to get the most aggressive findings and recommendations he could muster from the four remaining members of the five-man board. (Member John Goglia recused himself because, before joining the board, he worked on a post-crash team for USAir, where he was a mechanic.)

Bernard Loeb, the board's director of aviation safety, drafted a staff report and gave it to the board for the month-long "notation period," during which members ask questions and suggest revisions.

Loeb included among recommendations a number of far-reaching and costly proposals. He called for specific redesign and retrofitting of the 737 rudder so that it would include the kind of fail-safe design elements found in other Boeing jetliners.

In the next month, the board members each got their first views of the staff's computer simulations and received a "human factors" report from staffer Malcolm Brenner, who detailed how unlikely pilot error was a cause.

The simulations, combined with the Brenner report, left little doubt among the board members what the ultimate findings would be on the probable cause.

Then, another rudder problem

Fate also played a role: On Feb. 23, the day before Loeb gave his report to the board, an inadvertent rudder deflection forced a Metrojet 737 with 117 on board to make an emergency landing in Baltimore.

Though the safety board launched a massive investigation of that incident - scrutinizing the 737, taking apart the rudder assembly and even letting board members interview the jet's pilot - Hall refused to postpone the scheduled meeting on Flight 427.

Particularly significant to safety board member John Hammerschmidt was that the Metrojet 737 had been retrofitted with the very parts that the FAA and Boeing said already had addressed problems with the rudder system. To emphasize the point, board members met with the pilot of the jet involved in the incident.

"Even after they recovered from the rudder anomaly in flight . . . he (the Metrojet pilot) still noticed a rudder pulsing or bumping," Hammerschmidt said.

Board members, however, were not willing to accept Loeb's report without changes. In particular, some objected to the specific design recommendations.

"The strong consensus of the board is that it is not our responsibility to design the rudder," Hall said. "Our responsibility is to investigate the accidents."

Loeb accepted that. In the final compromise, a new panel that will include Boeing, the FAA and the NTSB will determine what additional 737 rudder modifications are needed.

In absolving United pilots Hal Greene and Patricia Eidson as well as USAir pilots Peter Germano and Charles Emmett of culpability in the Colorado Springs and Pittsburgh crashes, the NTSB raised another safety issue: Neither crew knew about the potential for a rudder reversal, nor that the 737's movable wing panels, called ailerons, are ineffective in countering uncommanded rudder deflections at lower speeds.

One recommendation calls for the FAA to evaluate a maneuver USAir and other airlines have adopted - flying 737s faster at lower altitudes to maintain the ailerons' ability to help offset rogue rudder deflections - and subsequently for the FAA to require Boeing to make flying faster on descent a mandatory procedure. Boeing officials said they see no need for the speed change.

The board also called on the FAA to fully implement past NTSB recommendations to order more sophisticated flight-data recorders on all 737s and to specifically train all 737 pilots to deal with rudder problems.

Beth Erickson, the FAA's director of aircraft certification service, said was noncommittal: "I think what we need to do is figure out what the board is looking for in terms of specific testing," she said. "We need to get with them and combine it with what we're already doing internally and move forward on it."

How fast and how far the FAA and Boeing now move could hinge in part on the growing clout of families of air-crash victims.

"I hope the FAA sees the passion of the NTSB and what it has accomplished," said Peter Germano, brother of Flight 427's captain. "This is an opportunity for the FAA to take what has been clearly demonstrated as the need to make some changes on one of the world's best airplanes and run with it.

"And I've got to believe there are engineers at Boeing who can't wait to go to work and make the corrections that have been pointed out here."