NTSB blames Alaska, FAA in Flight 261 crash
Wrapping up a three-year investigation, the board also found that the Federal Aviation Administration (FAA) allowed Alaska to engage in risky maintenance practices that directly led to the failure of a key mechanism in the tail section of the plane.
"The reason I think this is important is the FAA is the government, and the public trusts the government to ensure the safety of flight," said Carol Carmody, acting chairwoman of the board, as family members who lost relatives in the crash applauded. "I feel in this instance the FAA failed miserably."
The four-member board found that the FAA, without good reason, repeatedly allowed Alaska to reduce how often it lubricated the jackscrew assembly, the mechanism that failed, and check it for wear.
"The FAA did not fulfill its responsibility to properly oversee the maintenance operations at Alaska Airlines, and at the time of the accident, Federal Aviation Administration surveillance of Alaska Airlines had been deficient for at least several years," the board said.
The failures of Alaska and the FAA led to insufficient lubrication and excessive wear of the jackscrew assembly, the board concluded, identifying those factors as the primary cause of the crash.
The board also determined that a design flaw in the MD-83, built by McDonnell Douglas before its 1997 merger with Boeing, contributed to the crash. But it stopped short of recommending that the FAA order Boeing to redesign the plane's jackscrew assembly.
Instead, after a fierce debate, the board urged the FAA to identify ways to eliminate catastrophic flaws in the jackscrew system and, if practical, order the installation of fail-safe mechanisms.
That NTSB staff had recommended that the FAA require Boeing to redesign the system.
The board also rejected a staff proposal to ask the FAA to conduct a major new inspection of Alaska's maintenance programs.
The findings came nearly three years after the crash, which killed all 88 passengers and crew members Jan. 31, 2000, when the plane plunged into the Pacific Ocean off Southern California while heading to Los Angeles International Airport to make an emergency landing. The plane had left Puerto Vallarta, Mexico, with stops planned in San Francisco and then Seattle.
'Profound sorrow'
Alaska, which sent no top executive to yesterday's eight-hour hearing, issued a statement last night saying it agrees with many of the board's findings and "respectfully questions" others. The statement did not elaborate.
The airline, citing sweeping changes it made after the crash, also said it remains committed to safety and expressed its "profound sorrow" to the family and friends of the victims.
"For all of us, but particularly for those families and friends, this day marks yet another step on a long and difficult road," the airline said.
Alaska said the accident was the result of several factors, which it didn't identify, and that the airline "deeply regrets" that it occurred.
The board, in reaching its conclusions, rejected Alaska's long-held theory that a Boeing-approved grease corroded the jackscrew assembly.
The jackscrew is a 2-foot long, 1½-inch diameter threaded shaft that moves up and down, raising and lowering the leading edge of the stabilizer, the winglike structure on the tail that controls the plane's angle of flight.
'Within industry norms'
The FAA's chief spokeswoman, Laura Brown, said the safety board was correct in blaming Alaska for failing to adequately lubricate the jackscrew.
But she said the agency's approval of Alaska's maintenance intervals fell "well within industry norms" and that similar standards at other carriers did not lead to problems.
Brown said the FAA would review the board's recommendation for ways to make the jackscrew safer, such as installing indicators that would show jackscrew wear after each flight.
But she said the FAA does not think 2,100 MD-80-series planes and related aircraft in operation worldwide need to be redesigned.
The board found McDonnell Douglas' design of MD-80s and MD-90s and their predecessor, the DC-9, didn't adequately account for a catastrophic failure of the jackscrew assembly. Under federal rules, failure of one component is not supposed to cause a crash. Boeing no longer builds those planes, but it makes a smaller cousin, the 717, that has the same kind of jackscrew assembly, the board said.
Boeing spokeswoman Susan Bradley said the company would review the findings and determine if changes are needed. "Our goal is zero accidents," she said.
Boeing is working on better devices to measure jackscrew wear that board investigators yesterday described as highly promising.
Family members who attended the hearing said they were generally satisfied with the outcome. Several called yesterday's findings the "answer to a prayer."
Jim Busche of Seattle, whose son, Ryan Busche, 28, was killed in the crash, along with the younger Busche's wife, Abigail, 26, said the findings leave it to "the FAA and Alaska to consider their responsibility in this and provide an apology to family members."
"Especially from John Kelly," added his wife, Mariann Busche. Kelly is chairman of Alaska Air Group, the parent company of Alaska Airlines.
Jim Busche said although a study of the plane's design would be helpful, the families would like to see a fail-safe system that could have prevented the deaths of their family members.
Jeff Hatleberg, of Eugene, Ore., whose father, Glenn, 64, and mother, Barbara, 53, died in the accident, said the NTSB staff "did a wonderful job" in presenting information to the board members.
"I would like to see a formal apology from Alaska," he said. "I think that is not too much to ask and the morally right thing to do."
Hatleberg and members of other families were disappointed the board rejected the staff recommendation that the FAA conduct a major inspection of Alaska maintenance programs, similar to one carried out months after the crash. The earlier inspection forced Alaska to rewrite its maintenance manuals and hire hundreds of new mechanics and managers.
Inspection-plan opposition
The new inspection proposal was dropped primarily because of objections from board member John Goglia. He said the FAA should not focus so much attention on Alaska at a time when the airline industry is undergoing serious difficulties and two carriers, United Airlines and US Airways, are in bankruptcy proceedings.
In calling for the inspection, the NTSB staff cited four incidents since last spring in which Alaska mechanics had twice failed to properly lubricate a tail component in the rudders of MD-80s, and twice botched wear checks on jackscrew assemblies.
After the hearing, Goglia said he thought an inspection wasn't prudent because, although Alaska continues to have problems, it has made improvements.
"It's not changed," he said. "It's changing."
His concerns were supported by two other board members, George Black Jr. and John Hammerschmidt.
Alaska pilot Kevin Hampson, speaking for the Air Line Pilots Association, which has been highly critical of Alaska and the FAA, said he was mostly satisfied with the board's findings, noting the recommendation to study the jackscrew design would be helpful.
But, he said, "We're very unhappy they didn't call for a reinspection of the company."
Many of the issues addressed by the board will resurface in April, when more than 40 wrongful-death suits brought by family members are scheduled to go to trial in San Francisco. Other cases among the 88 original suits have been settled, all but one for undisclosed sums.
Jamie Lebovitz, a Cleveland attorney representing 18 families, said the board's finding of a design flaw was crucial, even if it didn't call for an immediate redesign. "Boeing set up Alaska for the failure," he said.
Boeing liability
Boeing faces potentially huge punitive damages in the suits, while Alaska doesn't because of an international treaty protecting carriers. Both companies could be required to pay costly damages for the pain and suffering of the victims, who experienced two steep dives and flew upside down before the plane hit the water.
Though those lawsuits continue, yesterday's hearing represented a culminating moment in the Alaska story. It began 14 months before the crash when the FBI and other federal investigators served a criminal search warrant on Alaska, searching for evidence of maintenance irregularities.
No criminal charges were filed. But the FAA, in a separate administrative review, ultimately found that Alaska and three of its managers had violated safety regulations, fining the carrier $44,000 and revoking the mechanic licenses of two of the managers and suspending the license of the third.
Throughout much of the scrutiny, Alaska has maintained that it had a good maintenance program and insisted, even as late as last week, that most of its mistakes were simply paperwork errors.
Steve Miletich: 206-464-3302 or smiletich@seattletimes.com.