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NTSB Blames Alaska Air Maintenance for 2000 Crash

Tuesday, December 10, 2002

WASHINGTON — Lax government oversight and shoddy maintenance practices by Alaska Airlines led to the crash of an airliner off the California coast that killed all 88 people aboard, federal investigators ruled Tuesday.

The National Transportation Safety Board said insufficient lubrication caused excessive wear and the eventual failure of the jet's jackscrew, a tail component that helps move the plane's stabilizer and sets the angle of flight.

The safety board rejected the airline's argument that the kind of grease recommended by Boeing Co. was at fault.

While the board said Alaska Airlines was primarily to blame for the Jan. 31, 2000, crash, it also said the Federal Aviation Administration bore some responsibility.

The FAA, which oversees airlines' maintenance programs, allowed Alaska Airlines to extend the intervals for greasing tail components and inspecting them for wear. The increased time between checks led to the lubrication problem, investigators said.

"The FAA is the government and I think the public trusts the government to ensure the safety of flight," NTSB Chairwoman Carol Carmody said. "I feel in this instance FAA failed miserably."

Relatives of victims who attended the NTSB meeting cheered when the board voted on the probable cause of the accident. Paige Stockley, 40, who lost her parents in the crash, carried a sign reading: "Corporate Greed Killed 88 People."

"It's like a closure. You don't have to wonder anymore," said Bernice Aragon, whose brother, sister-in-law and niece died in the crash.

FAA spokesman Les Dorr said the NTSB correctly focused on lack of lubrication as the primary cause. He defended the FAA's oversight, saying intervals between maintenance checks were well within industry norms.

Since the crash, the FAA has shortened the time allowed between lubrications and inspections for all airlines.

Alaska Airlines issued a statement saying it agrees with many of the NTSB findings and "respectfully questions others," though it did not specify them.

It also expressed deep regret for the crash and "profound sorrow" for the pain and loss suffered by relatives of victims. It noted steps it has taken to improve maintenance and safety, including hiring 300 additional employees, conducting more than 1,000 internal audits and commissioning a safety review by an outside entity.

"Since the accident, Alaska has enlisted the support of third party experts to scrutinize and help restructure, retool, and reorganize its operation to incorporate the best practices within the industry throughout its operation," the statement said.

Alaska Airlines Flight 261 took off from Puerto Vallarta, Mexico, with scheduled stops in San Francisco and Seattle. The pilots reported problems with handling and were planning to make an emergency landing in Los Angeles when the stabilizer broke off, causing the plane to roll over and dive into the Pacific Ocean.

Crash investigators later concluded the jackscrew mechanism on the jetliner had jammed soon after takeoff.

Alaska Airlines has said the jackscrew failed because of extreme wear caused by a kind of grease recommended by Boeing. The airline also blamed the design, saying the threads on the nut of the jackscrew assembly failed.

MD-80 planes were built by McDonnell Douglas, which Boeing bought in 1997.

Safety investigators said the airline industry uses unreliable techniques to check for wear on the jackscrew threads. The NTSB suggested that Boeing develop a more reliable test.

In a statement, Boeing said it is working on ways to make the inspections easier to perform and more reliable.

The board voted to recommend better procedures for lubricating the jackscrew mechanisms on DC-9, McDonnell Douglas MD-80/90 and Boeing 717 series airplanes.

Board members postponed a decision to recommend that those planes be retrofitted with a fail-safe mechanism to make sure a worn jackscrew part doesn't cause a crash. They did recommend that such a fail-safe mechanism be included in new horizontal stabilizer designs.

The safety board also recommended the FAA evaluate how the airline industry decides on maintenance intervals and that it make sure any changes undergo technical analysis.

After the crash, the FAA reviewed Alaska Airlines' maintenance practices and recommended that the carrier not be allowed to maintain its own planes if problems weren't fixed. The FAA now has 27 people overseeing Alaska Airlines, three times the number as when Flight 261 crashed.

The FAA also reviewed the maintenance programs of nine major airlines and reported in February that the carriers had made improvements.

Alaska Airlines and Boeing face wrongful-death lawsuits from the crash. Lawyer Jamie Lebovitz, who represents some of the victims' relatives, said the NTSB ruling strengthens their case.

Alaska Air crash report rips FAA
U.S. oversight blamed, along with carrier's maintenance practices

Henry K. Lee, Chronicle Staff Writer

Wednesday, December 11, 2002


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Lax federal oversight of Alaska Airlines' maintenance practices and the carrier's failure to check its planes often enough for wear and tear led to the fatal crash of an MD-80 jet off the Southern California coast in 2000, investigators concluded Tuesday.

The immediate reason for the crash of Alaska Airlines Flight 261 was lack of grease on a major tail component, which caused the plane to spiral out of control when the part failed, the National Transportation Safety Board said. But that part gave out because Alaska had cut back on its maintenance and the Federal Aviation Administration had allowed the airline to do so, the board said.

The FAA "failed miserably" to ensure that the airline kept its planes in good condition, the chairwoman of the National Transportation Safety Board said as the panel issued its findings in the crash of Flight 261.

All 88 people aboard died when the twin-engine jet bound for San Francisco and Seattle from Puerto Vallarta, Mexico, crashed upside-down into the Pacific on Jan. 31, 2000.

Members of the safety board, meeting in Washington, D.C., concluded that the probable cause of the crash was insufficient lubrication that led to excessive wear of the jackscrew, a part on the plane's horizontal stabilizer that controls up-and-down movement.

The plane's crew reported just before the crash that the stabilizer had jammed. When the jackscrew was recovered from the bottom of the ocean, investigators found almost no grease on it.

Contributing to the crash, the four-member safety board said, was Alaska's decision to extend the intervals between when maintenance crews lubricated the jackscrew and when they inspected it for wear. Those duties were performed by mechanics at the carrier's maintenance center at Oakland International Airport.

FAA SHARES BLAME
The FAA also was to blame because it hadn't objected to the airline's jackscrew inspection schedule, the board said.

"The FAA is the government, and I think the public trusts the government to ensure the safety of flight," said Carol Carmody, acting chairwoman of the safety board. "I feel in this instance FAA failed miserably."

FAA spokesman Les Dorr defended the agency's oversight of Alaska, saying intervals between maintenance inspections were within industry norms.

Plane manufacturer McDonnell Douglas, now owned by the Boeing Co., had recommended that jackscrew inspections be done every 30 months or 7,200 flight hours, whichever came first. The FAA approved Alaska's request in 1996 to drop the hourly requirement.

Alaska gradually increased the intervals between inspections and used its jets more hours per day, the safety board found. The plane that crashed in 2000 had accumulated 8,884 hours of flight time since its last jackscrew check.

In 1997, Alaska mechanics in Oakland recommended that the plane's jackscrew be replaced, but they were overruled by another crew.

Safety board lead investigator Richard Rodriguez sharply criticized the FAA,

saying the agency had been deficient in its oversight of Alaska's maintenance in Oakland "for several years prior to the accident."

The principal FAA maintenance inspector assigned to Alaska, now retired, said the agency was "too busy with administration to do any inspections," Rodriguez said.

AIRLINE'S EXPANSION
That same inspector, in a 1999 memo to his superiors, said Alaska was "in a state of aggressive growth and expansion" and that FAA staff was unable to keep up. As a result, the inspector concluded, "the risk of incidents or accidents at Alaska Airlines is heightened," the memo said.

Rodriguez recommended that the FAA begin a round of thorough inspections of Alaska maintenance facilities. But the board voted against the move, on the grounds that the airline already had conducted numerous internal audits since the crash.

Board member John Goglia said he was concerned that any undue attention on Alaska from FAA inspectors would detract from the agency's ability to pay attention to other airlines.

"Are we going to move people here and then have a problem pop up somewhere else on another carrier that should have received an inspection and didn't because we diverted the resources to satisfy us?" Goglia asked.

After much discussion, Carmody cut off the debate, saying, "We can't solve that today."

Last year, the U.S. attorney's office ended a three-year probe -- begun before the crash -- into allegations of maintenance improprieties at the Oakland center, saying no criminal charges would be filed.

The safety board also postponed a decision to recommend that MD-80 and related planes be retrofitted with backup mechanisms to prevent a crash caused by worn jackscrews.

In ruling on the probable cause, the board rejected the Seattle-based airline's contention that the type of grease recommended by Boeing was to blame for the crash.

"The only factor found to explain this level of severe wear is the lack of lubrication," said investigator Joseph Kolly.

In a statement Tuesday, Alaska acknowledged the safety board's findings but said it "respectfully questions" certain unspecified elements. The airline said it had taken steps to improve maintenance and expressed its "profound sorrow" for the families and friends of the Flight 261 victims.

Flight 261's crew struggled for more than 10 minutes to gain control of the aircraft after reporting that the stabilizer had jammed. Questions had been raised early in the investigation as to why the pilots tried to troubleshoot in the air instead of landing immediately.

On Tuesday, the board said said the pilots' decision to try an emergency landing in Los Angeles was "prudent and appropriate." But the board said that in such cases, "pilots should not attempt any additional corrective action" beyond basic checklist procedures.

No matter who is to blame, the crash was avoidable, said Chuck Hovey, 47, of Murphys (Calaveras County), whose older brother, Robert, of Emeryville, died aboard Flight 261.

"It's criminal, the way it was handled," he said. "I'm angry because my brother was killed because of an oversight of just trying to keep things going to make profits."




http://www.sfgate.com/cgi-bin/article.cgi?file=/chronicle/archive/2002/12/11/BU186211.DTL&type=business

"It's criminal, the way it was handled," he said. "I'm angry because my brother was killed because of an oversight of just trying to keep things going to make profits."

I couldn't agree more. I know just how he feels, unfortunately.

All of the presentations from yesterday’s Alaska’s final report can be seen at the following:

http://www.ntsb.gov/Events/2000/AKA261/presentations/presentations.htm