Air Emergency (2003–…): Season 1, Episode 5 - Cutting Corners - full transcript
In January 2000, Alaska Airlines flight 261 crashed off the Californian coastline with no survivors due to, as the title implies, improper maintenance.
This is a true story
The reconstructions are based on original cockpit
voice recordings and eyewitness accounts.
No family wants to loose a loved one,
daughter or son.
None of us thinks it is going to happen
to our family.
We read about these horrible crashes
and we think:
Thank God, you know
and chances are it won't happen to us
the odds are in our favour.
January, 2000
Alaska Airlines jet with 88 passengers
and crew suffered a catastrophic failure
that tore it from the sky
A shocking chain of negligence and error
led to disaster.
When a whistle blower mechanic from the airline
tried to sound the alarm about
faulty maintenance procedures
he was suspended from his job.
This investigation exposes deeply worrying
shortcomings in maintenance and regulations
that inflict the airline industry
and shows how a series of
devastating errors combined
produce a tragic accident,
one that could happen again.
CUTTING CORNERS
Puerto Vallarta is a popular holiday resort
on the Mexican Pacific Coast
one of several Mexican destinations,
served by Alaska Airlines.
Colleen Whirly went there
to celebrate a family birthday.
The 34 year old was a keen traveller
who spoke Spanish well
and had visited Mexico many times.
Colleen and the other holiday makers
returning from Puerto Vallarta
settle in for the 3:45 hr flight to San Francisco
In the warm afterglow of their holidays,
they are looking to the future.
Colleen and her fiance Monty
were planning to start a family later that year.
The pilots on Flight 261 are very experienced.
Both Captain Tedd Thompson
and first Officer Bill Tansky
have thousands of hours flying MD80s
They know the plane well.
The MD83 is one of a successful and popular
family of rear engine low flying planes.
Originally launched in 1980,
over a 1100 were delivered worldwide
But on January 31st, 2000,
as they prepared Flight 261
Thompson and Tansky had no idea
that deep in the plane's tail
lay a crucial weakness...
Colleen Whirly and her fiance Monty
were planning their forthcoming wedding.
They had announced their engagement
at Christmas time
It was a time for everybody to congratulate them
so, we decided:
We have a party for the family.
Abby Miller Busch had visited Mexico
with her husband Ryan and their friends
to celebrate her new job at Microsoft
It is hard to describe...
...how joyful a girl she was.
She was well known for that care
that she had in her
a trade that you cannot put a value on.
Dean and I have been there a lot together
and it was the first time that he went without me.
Dean taught me how to play,
he was always up
and told jokes a lot
people described him as a puppy dog.
Shortly after take off,
Captain Thompson and FO Tansky
get the first sign of trouble:
the horizontal stabilizer on the tailplane
won't move.
The pilots carry out a standard checklist
to try and free the stabilizer.
Stabilizer trim switch?
Normal
Circuit breakers, reset if tripped
D9, D10, D11 are okay
The stabilizer on the MD 83
is a 44 ft wide surface at the front of the tail.
It is like another wing.
Together with the elevators
at the rear of the tail
the stabilizer is used to adjust
the angle of the plane in flight.
The stabilizer wasn't moving
Thompson and Tansky assume that there was a fault
in the electric motors that move it up and down
They believed they could fix the problem.
They had no idea
they were in grave danger.
What they dealt with
was something that really snug up on
It was not supposed to be a big deal,
if it had been,
they would have turned around and
got back in to the Mexican airfield
So, it is perfectly alright to troubleshoot it
The pilots repeatedly tried the two switches
that operate the stabilizer.
The primary motor is activated by
both the switch on the control stick
known as the pickle switch
and the sliding suitcase handles
on the central console
Either system operative?
No!
Both systems inoperative,
consider stabilizer jam, do not use AUTOPILOT
The jammed stabilizer is pushing the aircraft down
toward the ground
At 28,500 ft, the pilots switch off the AUTOPILOT
and fly the plane manually.
They have to pull back hard on the control column
to push the nose of the plane up
This requires considerable physical efforts
by the pilots
The plane climbs for the next 7 minutes
to its cruising altitude of 32,000 ft.
As they fly up the coast
the pilots contact their airline's
maintenance department for assistance.
Maintenance, we need to know if any fault
like this has been reported for this aircraft
Were there any switches that you may not be
aware of to get those motors turning again?
Roger, 261, I can verify no history
on your aircraft in the past 30 days
Why didn't we see anything in the logbook?
I use the example of the average layman,
I think he can understand
if you try to start your car
and it doesn't crank:
you try jiggling the key in the socket
and try it again
and I think that the crew was (understandably)
going through a lot of these
'Maybe it will work now,
let's try this, let's try that'
The pilots need to think about what will happen
when they descend for landing
How will the plane behave?
will they be able to control it?
But several minutes after requesting help
from the ground
they are getting no advice.
as Flight 261 approaches Los Angeles off the coast
the problems on board were about to get far worse.
The pilots on the crippled Alaska Airlines 261
are flying manually at 32,000 ft
in a plane that has a jammed stabilizer
which is forcing its nose down.
The pilots have another go
at freeing up the jammed stabilizer.
They switch ON both the electric motors
that control it.
CAM-2 what are you doin?
CAM-1 It clicked off
From 31,000 ft,
Flight 261 plunges downwards for over a minute
The pilots battle for control
CAM-1
It * got worse… ok.
CAM-1
You're stalled.
At first, they hold back on the control column
to fight the dive
bu then the pilots push the nose down
into the dive to regain control
It is a risky manoeuvre,
pushing the plane's dive to 350 mph
CAM-1 No no you gotta release it
you gotta release it.
The pilots slowly bring the plane back
onto control
and bring the plane out of its dive.
CAM-1
lets * speedbrakes.
CAM-1
Gimme a high pressure pumps.
CAM-2
OK
CAM-1
Help me back help me back.
CAM-2
OK.
RDO-1 center
Alaska 261 we are in a dive here.
RDO-1
and I've lost control, vertical pitch.
LAX-CTR1
Alaska 261 say again sir.
RDO-1 yea were out of 26000 ft,
we are in a vertical dive…
not a dive yet
but we have lost vertical control of our airplane
CAM-1 just help me.
once we get the speed slowed maybe…
we'll be ok.
Maintaining level flight is not easy
The jammed stabilizer continues to
push the nose of the plane down
RDO-1
we're at 237 request .
RDO-1
yea we got it back under control here.
RDO-2
No, we don't, ok.
To counteract the downward force of the stabilizer
the pilots use the elevators,
moveable panels at the back of the tail
linked by cable to the control column
The pilots pull with all their might
The fate of the plane
hangs on the strength of their arms
In the cabin,
frightened passengers try to recover
from the terrifying plunge
They have no idea what might happen next
Holiday memories are replaced
by the fear of dying.
Dean was one of these people who would talk to
whoever was around him.
I am absolutely certain that he was talking
to the person that was sitting
next to him on the plane,
I am sure they had a connection
Colleen was very unique from my other kids
She loved to travel
She was a beautiful girl
She was a 25 year old
as if she had her own private rocket-ship
She was really going places
In the cockpit,
the pilots fight to control the speed
so that they can land.
They get a handful of airplane,
they get there stabilized
and they are now in a situation where
they make the decision properly
to go into an emergency landing
at Los Angeles International
CAM-2
Let's take the speedbrakes off
CAM-1 no no leave them there.
it seems to be helping.
OK, it really wants to pitch down.
CAM-1
Don't mess with that.
CAM-2
I agree with you.
With the plane under temporary control,
the pilots make the fateful decision
to do some more troubleshooting
They need a block of clear space
around the aircraft
in case they loose control again;
they contact Air Traffic Control
LAX-CTR1
Alaska 261, say your condition.
RDO-1
261, We are at 24,000 ft, kinda stabilized.
We're slowing here, and uh, we're gonna uh
We are going to do a little troubleshooting
Can you give me a block
between 20,000 and 25,000 ft
LAX-CTR1: Alaska Flight 261
maintain block altitude flight level 20,000ft
through flight level 25,000 ft
The pilots now have
clear airspace above and below the plane
They try to figure out their next move
CAM-2
You have the airplane, let me just try it.
CAM-2 uh how hard is it?
CAM-1 I don't know my adrenaline's goin…
it was really tough there for a while.
CAM-2
yea it is.
CAM-2
whatever we did is no good, don't do that again.
CAM-1
yea, no it went down it went to full nose down.
CAM-2
it's a lot worse than it was?
CAM-1
we're in much worse shape now.
The pilots know
this is no mere an electrical problem
From what they've experienced,
they assume the stabilizer is now jammed.
CAM-1
I think its at the stop, full stop
and I'm thinking, can it get any worse…
but it probably can
Let's slow it,
let's get down to 200 knots and see what happens
The crisis is worse than ever
Uncertain how the plane will react,
if they try to slow it down
The pilots must still pull on the elevators
to maintain level flight.
Captain Thompson once again
tries to get help from maintenance
RDO-1
Maintenance 261 are you on?
LAX-MX-2
yea 261, this is maintenance.
RDO-1 --- we did both the pickle switch
and the suitcase handles
and it ran away full nose trim down.
LAX-MX-2
oh it ran away trim down?
RDO-1
and now we're in a * pinch
so we're holding
we're worse than we were before.
LAX-MX-1 you getting full nose trim down but
you don't get no nose trim up is that correct?
RDO-1
that's affirm
we went to full nose down
and I'm afraid to try it again to see
if we can get it in the other direction.
LAX-MX-1
ok well your discretion
if you want to try it, that's OK with me
if not that's fine.
we'll see you at the gate.
As important as it is to have that ground contact
with people with maintenance manuals
and experience on the ground
and the ability to call up the manufacturer
It is not always going to give you a magic answer.
the crew had already gone through every
logic tree they can possibly think of
Maintenance clearly does not appreciate
the significance of the situation
and this is the last the crew will hear from them
No one can help the pilots now
as they struggle with the jammed stabilizer.
Ever professional, however,
they try to put the passengers at ease.
PA-1 folks we have had
a flight control problem up front here
we're workin it
that's Los Angeles off to the right there
That's where we're intending to go.
We're pretty busy up here
working this situation
I don't anticipate any big problems
once we get a couple of sub systems on the line.
but we will be going into LAX and I'd anticipate
us parking there in about 20 to 30 minutes.
In fact, they will never make it to Los Angeles
But that is just the beginning
of a real life horror story jet to unfold
After the terrifying 8000 ft plunge downwards
Alaska Airlines 261 has now levelled out
RDO-2
L A Alaska 261 ,we're with you
We're at 22,500 ft, we have a jammed stabilizer
and we're maintaining
altitude with difficulty.
but we can maintain altitude we think...
and our intention is to land at Los Angeles.
The pilots request to be routed out over
the Pacific Ocean, away from the airport
RDO-1: center Alaska 261. I need to get down 10,
change my configuration,
to make sure I can control the jet
and I'd like to do that out here
over the bay if I may.
If the worst happens,
the pilots don't want to kill people on the ground
as well as in the plane
There are a lot of lives saved
(People don't realize)
by the fact that this crew said:
Let's stay over the water
until we got this thing completely under control
As they manoeuvre over the ocean,
the crew again asked Air Traffic Control
to keep the space around the plane clear
Alaska 261, fly a heading of 280 and descend
and maintain 17,000.
280 and 17,000 ft Alaska 261.
and we're generally needing a block altitude.
Hi, Debby, I need everything picked up
and everybody strapped down
The pilots concentrate on trying to fix the plane
even though they don't
know what will happen
I'm just flying now
It's only the pitch over
CAM-2 ok... get some power on
CAM-1 I'm at 250 knots
CAM-2 real hard?
CAM-1 no actually its pretty stable right here...
see but we got to get down to a 180
The pilots try to slow the aircraft down
to landing speed without loosing control
but as they inch their way towards a solution,
every move they make
could have fatal consequences
The only hope for the passengers
is that the pilot's skill and experience
can get the plane to Los Angeles Airport
CAM-1 it's on the stop now, its on the stop.
CAM-2 well not according to that its not.
As one effort after another fails,
the crew wonder if the stabilizer is damaged
CAM-2 the trim might be
and then it might be
if something's popped back there...
CAM-2 it might be a mechanical damage, too
CAM 2: I think if it's controllable,
we ought just try to land it
Do you think so?
Okay, lets head for L. A.
But just as they prepare to land on Los Angeles,
something gives away in the tail of the plane
CAM-2
Did you feel that?
OK gimme slats
see, this is a bitch.
The plane dives straight down from 18,000 ft
To avoid collisions,
LAX has warned the pilots of nearby planes
that Alaska 261 is in difficulty
These pilots now report back to the tower
That plane has just started to do
a big huge plunge
Yer, sir, he is definitively in a nose down
position, descending quite rapidly.
Definitely out of control
The plane is inverted, sir
Okay, he is inverted
The pilots have difficulty reaching the controls
The plane is upside down,
but they believe they might be able
to roll the plane out of the dive
mayday.
CAM-1 push and roll, push and roll.
CAM-1 kick *
CAM-1 push push push...
push the blue side up.
They try to fly the airplane even upside down
and they never for a moment believed
that they could not find a way
to control this airplane
CAM-1: push.
CAM-2: I'm pushing.
CAM-1: Okay now lets kick rudder...
left rudder left rudder.
CAM-2: I can't reach it
CAM-1: OK right rudder...
right rudder.
The plane was being knocked from side to side
it turned upside down
It was spinning,
persons were being thrown against the walls
of the plane, falling out of their seats
Cockpit Voice Recorder screaming
Unbelievable...
horrible last few minutes of their lives
CAM-1 Are we flying? we're flying, we're flying...
Tell 'em what we're doing.
CAM-2 Oh yea Let me get dammit
And it was so violently upside down that the
pilots were hanging from their shoulder straps
CAM-1 Ah, Here we go.
Yes, he just hit the water
Ah, yes sir, He ...
He hit the water, he is down
After a terrifying 67 seconds dive
Flight 261 hit the Pacific Ocean
at close to 250 mph.
Rescue helicopters are soon at the crash site
but there were no survivors
The plane had broken up on impact
88 passengers and crew,
including 3 young children...
died instantly
Fred Miller lost his daughter Abby
and her husband Ryan.
These people suffered on the way down,
this was not a pretty way to die.
One witness said it spun at times,
almost like a spinning top
And he said: 'To think:
People...
somebody who has a life
to live is in there
dying'
He said 'It is one of the most horrifying memories
I will ever have.
Susan Da Silva lost her husband Dean
I know that they went through a horrible,
horrible experience.
And this was a violent end
these people suffered,
There were no bodies that were intact
or even close to intact
and they were conscious for a long time
before it all came apart.
Colleen Whirley died, along with her fiance Monty
As a mother,
keep waiting for her child to come home
And Colleen had travelled so much in her life.
it was unusual
not to have her just walking in the door
All this time you are thinking
something caused this,
something made this happen
And I want to find out:
Who is responsible for this?
Investigation into Alaska Airlines Flight 261
began to swing into gear
but the wreckage lay 700 ft down.
So NTSB officials called on NAVY submersibles
to retreat the plane from the seabed.
We set up the base of operations
The other ROV with the site-scanning sonar
which they use to map the debris-field
to get an idea of
how widely spread the wreckage was.
At the NTSB Headquarters in Washington
the investigator's immediate concern
was to find out what had brought the plane down.
The first clues came from the CVR
We immediately suspected
some problem in the tail of the airplane
which is where the controls are
Just something was wrong back there
That was the key piece of wreckage to look for.
The MD 83 that crashed was
a revised version of the Douglas Corporation's DC9
It was an extremely popular plane
Over 2000 were delivered to airlines worldwide
The engines were at the rear of the plane
and the distinctive T-shaped tail
was an essential element of the design.
In a big triple jet aircraft,
one of the rather brilliant elements of the design
is that, since you are going to
loading passengers and cargo,
you want to be able to have that aircraft loaded
a little nose heavier than a little tail heavy
In order to do that,
you have to have that entire stabilizer moving
but the most difficult thing to
engineer are the T-tailed airplanes
where you have the vertical stabilizer
and the horizontal sitting on top
and we call that: Stabilizer trim
and that is an essential element
of what makes these aircraft so useable
In the MD83, a motorized jack screw in the tail
moves the horizontal stabilizer up and down
As the stabilizer moves up,
the nose of the airplane moves down
As the stabilizer moves down
the nose of the airplane moves up
But what role had the 77cm long jack-screw played
in the loss of Flight 261?
The investigators were anxious to inspect it
as soon as it was recovered from the seabed.
The jack-screw wasn't mated with the nuts
that it screws in to
It was just by itself.
The nut was found in another piece of structure
a few feet away from where the jack-screw was.
To have a screw separated itself from a nut
with very thick threads
surprised us
Secondly,
we noticed that there was a curled
piece of rasp around the jack-screw
and all the threads that you can see here,
these ridges, were gone
They have been stripped out
and the remnants of those were found,
coiled on the jack-screw.
Once the thread had been stripped of the nut,
the jack-screw could no longer turn
The pilots could not have known
the real nature of the problem.
The crew was confronted with a situation
that had never occurred before.
There is no failed jack-screw procedure
In the QRH's that they have available
there is no training for it.
When the jack screw jammed,
the pilots were unable to adjust the stabilizer
We felt that it was due to the fact
that these nut-threads had worn away
and it was just too hard for that jack screw
under the power of the electric motor to turn
That gave the flight crew an indication
that there was a problem.
The crew knew they had a problem in the tailplane
but they had no idea what.
Two motors control the jack screw
and they tried each of them in turn.
But the pilot's attempts to free the stabilizer
made their situation worse
Where they went wrong was
that they wanted to try both the alternate
and the primary trim motors at the same time.
When the pilots switched both
the electrical motors on,
the jack screw moved
but the threads have given way
and the jack-screw was now held
only by a single retaining nut
From this point on, the plane was doomed.
That end nut was never designed to hold the loads,
generated aerodynamically by the tailplane.
Now we know, in the glaring light of hind-sights
now when turn the situation around in time
and look back
we can see that this
aircrew and no aircrew
should have been ever fooling with the trim
and trying to run it back and forth.
The retaining nut grew weaker and weaker
Then, finally
through a loads beating down on that nut
the nut finally failed
The jack-screw slid completely out of the nut,
allowing the horizontal stabilizer to
move well beyond its aerodynamic limits
The stabilizer forced the plane down
and is now completely out of control
it rolled over into its final dive.
This crew was working to recover the aircraft
right down to the water
They did not give up
the whole way down through the descend.
It was clear to the investigators
that the failure of the jack-screw
was the only explanation
for the erratic flightpath and final dive
But why had this happened?
Why had the jack-screw failed?
The investigators begin looking deeper and deeper
into the condition of the faulty jack screw
What had caused it to fail
There was no lubrication or visible grease
on the working area of the screw
That was surprising and strange.
The discovery of no grease on the jack-screw
alarmed the investigators.
They alerted the FAA
to order an immediate check
on all the MD 80s in the USA.
They made a shocking discovery.
At Alaska Airlines,
in 6 of its fleet of 34 planes,
the jack-screw assembly needed to be replaced
after failing new inspections.
No grease is the culprit
No grease or inadequate grease
is the only thing that can give you that wear
A simple lack of grease led to the failure of
a jack-screw and the loss of 88 lives
Why did this happen at Alaska Airlines?
The investigator's attention now switched
to the company's maintenance program.
What emerged, was deeply worrying
We interviewed all the mechanics
who had worked on these airplanes
We knew that they had been falsifying records
or not doing the work they had indicated
The mechanics at Alaska indicated that they were
pressured to keep the planes in the air
or that their recommendations were overruled
by supervisors.
Some alleged that records were altered to show:
WORK DONE that was not done
Alaska has long been one of America's
most successful airlines
but in the early 1990's
the economic downturn began
to hit the company hard.
Its response was to slash costs
to revive its fortunes.
Alaska Airlines began flying the planes
more intensively.
It sharply increased
the average daily use of its fleet
Keeping the planes in the air earning money
puts maintenance schedules under pressure.
John Liotine was a lead mechanic at Alaska
Airlines Oakland maintenance facility
where he worked for over 8 years.
Liotine felt that the new pressure on maintenance
put passengers' lives at risk
He was to paid dearly
for expressing those concerns
We have used an actor to portray his experiences
based on his sworn evidence to the NTSB.
Liotine claimed that planes were pushed back
into service too quickly.
Sometimes, rather than wait for
a replacement part or repair,
supervisors passed planes fit for service
free to carry passengers up into the air.
In October, 1998
over 15 Months before the crash
John Liotine became so worried
that he did something that
would chance his life forever.
He reported Alaska Airlines to the US FAA
alleging violations in maintenance procedures.
There were very few voices at Alaska
who had concerns about the maintenance
There should have been more and there should
have been people listening to John Leotine
He is a hero in my book.
In December 1999,
over a year before the crash,
The FAA and the department of transportation
officials moved on Alaska Airlines
The case was referred to federal prosecutors
and the FBI rated Alaska's maintenance facilities
and sees thousands of records.
The raid was the opening shot in the Federal Grand
Jury investigation that would last 3 years
No criminal charges were brought
against the company
Alaska Airlines officials deny that
any unsafe planes were put into service
or that passengers' lives were ever at risk.
But the investigation revealed
hundreds of violations of Federal regulations
Alaska Airlines was fined.
The FAA insisted on changes to the company's
maintenance and safety procedures.
The FAA also suspended two supervisors
for falsifying records.
Like other whistle-blowers,
John Liotine would pay heavily
for his efforts to save lives.
Alaska Airlines put him
on a paid leave from his job
costing him thousands of dollars
in regular overtime earnings.
Then, in January 2000,
John Liotine saw his worst nightmare come true
the kind of accident he had tried to prevent
by contacting the Federal Authorities
now took place,
just off the California coast.
After the crash of Flight 261,
John Liotine went back to his own work records
Incredibly, he found
that he had a direct link to the crashed airliner.
Over 2 years before at the plane's last overhaul
he had ordered the jack-screw on this
particular aircraft be replaced
He then went off shift.
When investigators examined the record
they found that Liotine's recommendations
had been overruled by the next shift
and the plane put back into service.
It would be 2,5 years before the next overhaul
but time ran out.
Two months before the overhaul was due
Flight 261 crashed.
Alaska Airlines labelled Liotine
at disruptive influence
Later, he sued the company for liable.
Alaska settled
but Liotine could no longer
work in the industry he loved.
I get calls on every week somebody saying
Should I blow the whistle?
And I always tell them
You need to know you need to be prepared
to find another line of work
because you will not work in the industry
and not in the government
In most cases,
it is almost impossible to be a whistle-blower
and to survive your career.
As the investigators continued their work
in Flight 261
they made another disturbing discovery
about the drive to cut costs at Alaska Airlines
To keep planes flying more intensively,
Alaska had dramatically extended
the intervals between service.
This was significant,
because when a plane is designed
every part has a scheduled listing
when it is serviced and when it must be replaced.
You supposed to go and inspect
in a every x hours
and that is different on parts
all over the plane
Some things you have to look at
after every flight
other things have to inspected every 2 or 3 days.
By 1996,
Alaska Airlines extended the intervals between
MD 83's jack-screw lubrications by 400%
Now, there was over 2,500 hours
between each service.
The extended service intervals would approve fatal
for Flight 261.
If you had 600 hours between
inspection points and greasing points
we have no chance of ever having
a metal to metal contact situation
but if you put that over 2000...2500 hours
now what you do is:
Eat in to some of these protective barriers
that we have towards catastrophic failure.
In its final report of
the crash of Flight 261
the NTSB concluded that Alaska Airlines' extended
service intervals for the jack-screws on its MD80s
was a significant contributor to the crash.
With harriers
doing everything to save a dime
maintenance, safety
And the shocking thing about Alaska is that they
were allowed to increase inspection intervals
It is shocking,
because that is the only way we have safety.
The extended maintenance intervals meant
that the lack of grease on the jack-screw
was not discovered before the crash.
But now, investigators wondered if the failure
of the jack-screw-assy
revealed a basic flaw in the plane's design.
They discovered that the MD 80 broke one of
the fundamental rules of aircraft design
It was not fail-safe
The design philosophy
that has made aviation so safe, is that
we should never have a situation in which
one catastrophic failure of some component
causes it to lose that airplane.
There was no back up
to the jack-screw and its nut.
Engineers never envisioned a situation
on the MD 80 where the jack-screw might fail.
With inspections every 600 flight hours
and replacement every 2000 hours,
the designers did not add
an additional redundant back up system.
It was utterly laughable
that they said it was a redundant system,
There is one screw and there is one nut
That is all there is; it is not redundant.
The MD 80 continues to fly worldwide
despite the revelation
of this potentially dangerous design flaw
the jack-screw assembly has not been redesigned.
Inspection intervals have been shortened
but airlines still rely on proper maintenance
to prevent the same accident happening again.
In its final report, the NTSB concluded
that the crash of flight 261
was due to the lack of adequate greasing
and the stretched service intervals.
When coupled with the design of the jack-screw
these failures led to
a completely avoidable accident
and the loss of 88 lives.
Three years after the crash
the relatives and friends of the dead
dedicated a permanent memorial
at port close Hueneme
close to the crash site.
I think the best thing and the only thing
in our infinite inadequacy
of making up for the loss of these lives
is to say something we've been able to say
in a lot of other accidents to grieving families,
and that is: those deaths will not be in vain
We will not let them be in vain
Every one of those lives will be made
to count in terms of making sure
that 3, 4, 5 or 10 people do not die.
Colleen was different,
she was adventurous
and there is nobody like that in our family.
I don't know what we can do
except to remember Colleen
and to live our lives now a little bit better
for her
When I was growing up
we didn't wear seat-belts
There weren't even seat-belts in cars.
Now we know that we need to wear seat-belts.
We didn't know much about smoking cigarettes
And now, we know that we can't smoke cigarettes
There is a lot to learn about airline safety, too
None of us is the same, anymore
It is like walking into a giant storm.
Wave after wave, forming up
coming in
because it never stops.
Grieve over the loss of a child is not something
I wish on anybody.
This plane went down because of neglect.
It seems like such an unholy type of loss
What a hard way to die,
so, an airline can...
...make more money.
Narrated by
Stephen Bogaert
Subtitles
Rein Croonen and transcript from the CVR.
The reconstructions are based on original cockpit
voice recordings and eyewitness accounts.
No family wants to loose a loved one,
daughter or son.
None of us thinks it is going to happen
to our family.
We read about these horrible crashes
and we think:
Thank God, you know
and chances are it won't happen to us
the odds are in our favour.
January, 2000
Alaska Airlines jet with 88 passengers
and crew suffered a catastrophic failure
that tore it from the sky
A shocking chain of negligence and error
led to disaster.
When a whistle blower mechanic from the airline
tried to sound the alarm about
faulty maintenance procedures
he was suspended from his job.
This investigation exposes deeply worrying
shortcomings in maintenance and regulations
that inflict the airline industry
and shows how a series of
devastating errors combined
produce a tragic accident,
one that could happen again.
CUTTING CORNERS
Puerto Vallarta is a popular holiday resort
on the Mexican Pacific Coast
one of several Mexican destinations,
served by Alaska Airlines.
Colleen Whirly went there
to celebrate a family birthday.
The 34 year old was a keen traveller
who spoke Spanish well
and had visited Mexico many times.
Colleen and the other holiday makers
returning from Puerto Vallarta
settle in for the 3:45 hr flight to San Francisco
In the warm afterglow of their holidays,
they are looking to the future.
Colleen and her fiance Monty
were planning to start a family later that year.
The pilots on Flight 261 are very experienced.
Both Captain Tedd Thompson
and first Officer Bill Tansky
have thousands of hours flying MD80s
They know the plane well.
The MD83 is one of a successful and popular
family of rear engine low flying planes.
Originally launched in 1980,
over a 1100 were delivered worldwide
But on January 31st, 2000,
as they prepared Flight 261
Thompson and Tansky had no idea
that deep in the plane's tail
lay a crucial weakness...
Colleen Whirly and her fiance Monty
were planning their forthcoming wedding.
They had announced their engagement
at Christmas time
It was a time for everybody to congratulate them
so, we decided:
We have a party for the family.
Abby Miller Busch had visited Mexico
with her husband Ryan and their friends
to celebrate her new job at Microsoft
It is hard to describe...
...how joyful a girl she was.
She was well known for that care
that she had in her
a trade that you cannot put a value on.
Dean and I have been there a lot together
and it was the first time that he went without me.
Dean taught me how to play,
he was always up
and told jokes a lot
people described him as a puppy dog.
Shortly after take off,
Captain Thompson and FO Tansky
get the first sign of trouble:
the horizontal stabilizer on the tailplane
won't move.
The pilots carry out a standard checklist
to try and free the stabilizer.
Stabilizer trim switch?
Normal
Circuit breakers, reset if tripped
D9, D10, D11 are okay
The stabilizer on the MD 83
is a 44 ft wide surface at the front of the tail.
It is like another wing.
Together with the elevators
at the rear of the tail
the stabilizer is used to adjust
the angle of the plane in flight.
The stabilizer wasn't moving
Thompson and Tansky assume that there was a fault
in the electric motors that move it up and down
They believed they could fix the problem.
They had no idea
they were in grave danger.
What they dealt with
was something that really snug up on
It was not supposed to be a big deal,
if it had been,
they would have turned around and
got back in to the Mexican airfield
So, it is perfectly alright to troubleshoot it
The pilots repeatedly tried the two switches
that operate the stabilizer.
The primary motor is activated by
both the switch on the control stick
known as the pickle switch
and the sliding suitcase handles
on the central console
Either system operative?
No!
Both systems inoperative,
consider stabilizer jam, do not use AUTOPILOT
The jammed stabilizer is pushing the aircraft down
toward the ground
At 28,500 ft, the pilots switch off the AUTOPILOT
and fly the plane manually.
They have to pull back hard on the control column
to push the nose of the plane up
This requires considerable physical efforts
by the pilots
The plane climbs for the next 7 minutes
to its cruising altitude of 32,000 ft.
As they fly up the coast
the pilots contact their airline's
maintenance department for assistance.
Maintenance, we need to know if any fault
like this has been reported for this aircraft
Were there any switches that you may not be
aware of to get those motors turning again?
Roger, 261, I can verify no history
on your aircraft in the past 30 days
Why didn't we see anything in the logbook?
I use the example of the average layman,
I think he can understand
if you try to start your car
and it doesn't crank:
you try jiggling the key in the socket
and try it again
and I think that the crew was (understandably)
going through a lot of these
'Maybe it will work now,
let's try this, let's try that'
The pilots need to think about what will happen
when they descend for landing
How will the plane behave?
will they be able to control it?
But several minutes after requesting help
from the ground
they are getting no advice.
as Flight 261 approaches Los Angeles off the coast
the problems on board were about to get far worse.
The pilots on the crippled Alaska Airlines 261
are flying manually at 32,000 ft
in a plane that has a jammed stabilizer
which is forcing its nose down.
The pilots have another go
at freeing up the jammed stabilizer.
They switch ON both the electric motors
that control it.
CAM-2 what are you doin?
CAM-1 It clicked off
From 31,000 ft,
Flight 261 plunges downwards for over a minute
The pilots battle for control
CAM-1
It * got worse… ok.
CAM-1
You're stalled.
At first, they hold back on the control column
to fight the dive
bu then the pilots push the nose down
into the dive to regain control
It is a risky manoeuvre,
pushing the plane's dive to 350 mph
CAM-1 No no you gotta release it
you gotta release it.
The pilots slowly bring the plane back
onto control
and bring the plane out of its dive.
CAM-1
lets * speedbrakes.
CAM-1
Gimme a high pressure pumps.
CAM-2
OK
CAM-1
Help me back help me back.
CAM-2
OK.
RDO-1 center
Alaska 261 we are in a dive here.
RDO-1
and I've lost control, vertical pitch.
LAX-CTR1
Alaska 261 say again sir.
RDO-1 yea were out of 26000 ft,
we are in a vertical dive…
not a dive yet
but we have lost vertical control of our airplane
CAM-1 just help me.
once we get the speed slowed maybe…
we'll be ok.
Maintaining level flight is not easy
The jammed stabilizer continues to
push the nose of the plane down
RDO-1
we're at 237 request .
RDO-1
yea we got it back under control here.
RDO-2
No, we don't, ok.
To counteract the downward force of the stabilizer
the pilots use the elevators,
moveable panels at the back of the tail
linked by cable to the control column
The pilots pull with all their might
The fate of the plane
hangs on the strength of their arms
In the cabin,
frightened passengers try to recover
from the terrifying plunge
They have no idea what might happen next
Holiday memories are replaced
by the fear of dying.
Dean was one of these people who would talk to
whoever was around him.
I am absolutely certain that he was talking
to the person that was sitting
next to him on the plane,
I am sure they had a connection
Colleen was very unique from my other kids
She loved to travel
She was a beautiful girl
She was a 25 year old
as if she had her own private rocket-ship
She was really going places
In the cockpit,
the pilots fight to control the speed
so that they can land.
They get a handful of airplane,
they get there stabilized
and they are now in a situation where
they make the decision properly
to go into an emergency landing
at Los Angeles International
CAM-2
Let's take the speedbrakes off
CAM-1 no no leave them there.
it seems to be helping.
OK, it really wants to pitch down.
CAM-1
Don't mess with that.
CAM-2
I agree with you.
With the plane under temporary control,
the pilots make the fateful decision
to do some more troubleshooting
They need a block of clear space
around the aircraft
in case they loose control again;
they contact Air Traffic Control
LAX-CTR1
Alaska 261, say your condition.
RDO-1
261, We are at 24,000 ft, kinda stabilized.
We're slowing here, and uh, we're gonna uh
We are going to do a little troubleshooting
Can you give me a block
between 20,000 and 25,000 ft
LAX-CTR1: Alaska Flight 261
maintain block altitude flight level 20,000ft
through flight level 25,000 ft
The pilots now have
clear airspace above and below the plane
They try to figure out their next move
CAM-2
You have the airplane, let me just try it.
CAM-2 uh how hard is it?
CAM-1 I don't know my adrenaline's goin…
it was really tough there for a while.
CAM-2
yea it is.
CAM-2
whatever we did is no good, don't do that again.
CAM-1
yea, no it went down it went to full nose down.
CAM-2
it's a lot worse than it was?
CAM-1
we're in much worse shape now.
The pilots know
this is no mere an electrical problem
From what they've experienced,
they assume the stabilizer is now jammed.
CAM-1
I think its at the stop, full stop
and I'm thinking, can it get any worse…
but it probably can
Let's slow it,
let's get down to 200 knots and see what happens
The crisis is worse than ever
Uncertain how the plane will react,
if they try to slow it down
The pilots must still pull on the elevators
to maintain level flight.
Captain Thompson once again
tries to get help from maintenance
RDO-1
Maintenance 261 are you on?
LAX-MX-2
yea 261, this is maintenance.
RDO-1 --- we did both the pickle switch
and the suitcase handles
and it ran away full nose trim down.
LAX-MX-2
oh it ran away trim down?
RDO-1
and now we're in a * pinch
so we're holding
we're worse than we were before.
LAX-MX-1 you getting full nose trim down but
you don't get no nose trim up is that correct?
RDO-1
that's affirm
we went to full nose down
and I'm afraid to try it again to see
if we can get it in the other direction.
LAX-MX-1
ok well your discretion
if you want to try it, that's OK with me
if not that's fine.
we'll see you at the gate.
As important as it is to have that ground contact
with people with maintenance manuals
and experience on the ground
and the ability to call up the manufacturer
It is not always going to give you a magic answer.
the crew had already gone through every
logic tree they can possibly think of
Maintenance clearly does not appreciate
the significance of the situation
and this is the last the crew will hear from them
No one can help the pilots now
as they struggle with the jammed stabilizer.
Ever professional, however,
they try to put the passengers at ease.
PA-1 folks we have had
a flight control problem up front here
we're workin it
that's Los Angeles off to the right there
That's where we're intending to go.
We're pretty busy up here
working this situation
I don't anticipate any big problems
once we get a couple of sub systems on the line.
but we will be going into LAX and I'd anticipate
us parking there in about 20 to 30 minutes.
In fact, they will never make it to Los Angeles
But that is just the beginning
of a real life horror story jet to unfold
After the terrifying 8000 ft plunge downwards
Alaska Airlines 261 has now levelled out
RDO-2
L A Alaska 261 ,we're with you
We're at 22,500 ft, we have a jammed stabilizer
and we're maintaining
altitude with difficulty.
but we can maintain altitude we think...
and our intention is to land at Los Angeles.
The pilots request to be routed out over
the Pacific Ocean, away from the airport
RDO-1: center Alaska 261. I need to get down 10,
change my configuration,
to make sure I can control the jet
and I'd like to do that out here
over the bay if I may.
If the worst happens,
the pilots don't want to kill people on the ground
as well as in the plane
There are a lot of lives saved
(People don't realize)
by the fact that this crew said:
Let's stay over the water
until we got this thing completely under control
As they manoeuvre over the ocean,
the crew again asked Air Traffic Control
to keep the space around the plane clear
Alaska 261, fly a heading of 280 and descend
and maintain 17,000.
280 and 17,000 ft Alaska 261.
and we're generally needing a block altitude.
Hi, Debby, I need everything picked up
and everybody strapped down
The pilots concentrate on trying to fix the plane
even though they don't
know what will happen
I'm just flying now
It's only the pitch over
CAM-2 ok... get some power on
CAM-1 I'm at 250 knots
CAM-2 real hard?
CAM-1 no actually its pretty stable right here...
see but we got to get down to a 180
The pilots try to slow the aircraft down
to landing speed without loosing control
but as they inch their way towards a solution,
every move they make
could have fatal consequences
The only hope for the passengers
is that the pilot's skill and experience
can get the plane to Los Angeles Airport
CAM-1 it's on the stop now, its on the stop.
CAM-2 well not according to that its not.
As one effort after another fails,
the crew wonder if the stabilizer is damaged
CAM-2 the trim might be
and then it might be
if something's popped back there...
CAM-2 it might be a mechanical damage, too
CAM 2: I think if it's controllable,
we ought just try to land it
Do you think so?
Okay, lets head for L. A.
But just as they prepare to land on Los Angeles,
something gives away in the tail of the plane
CAM-2
Did you feel that?
OK gimme slats
see, this is a bitch.
The plane dives straight down from 18,000 ft
To avoid collisions,
LAX has warned the pilots of nearby planes
that Alaska 261 is in difficulty
These pilots now report back to the tower
That plane has just started to do
a big huge plunge
Yer, sir, he is definitively in a nose down
position, descending quite rapidly.
Definitely out of control
The plane is inverted, sir
Okay, he is inverted
The pilots have difficulty reaching the controls
The plane is upside down,
but they believe they might be able
to roll the plane out of the dive
mayday.
CAM-1 push and roll, push and roll.
CAM-1 kick *
CAM-1 push push push...
push the blue side up.
They try to fly the airplane even upside down
and they never for a moment believed
that they could not find a way
to control this airplane
CAM-1: push.
CAM-2: I'm pushing.
CAM-1: Okay now lets kick rudder...
left rudder left rudder.
CAM-2: I can't reach it
CAM-1: OK right rudder...
right rudder.
The plane was being knocked from side to side
it turned upside down
It was spinning,
persons were being thrown against the walls
of the plane, falling out of their seats
Cockpit Voice Recorder screaming
Unbelievable...
horrible last few minutes of their lives
CAM-1 Are we flying? we're flying, we're flying...
Tell 'em what we're doing.
CAM-2 Oh yea Let me get dammit
And it was so violently upside down that the
pilots were hanging from their shoulder straps
CAM-1 Ah, Here we go.
Yes, he just hit the water
Ah, yes sir, He ...
He hit the water, he is down
After a terrifying 67 seconds dive
Flight 261 hit the Pacific Ocean
at close to 250 mph.
Rescue helicopters are soon at the crash site
but there were no survivors
The plane had broken up on impact
88 passengers and crew,
including 3 young children...
died instantly
Fred Miller lost his daughter Abby
and her husband Ryan.
These people suffered on the way down,
this was not a pretty way to die.
One witness said it spun at times,
almost like a spinning top
And he said: 'To think:
People...
somebody who has a life
to live is in there
dying'
He said 'It is one of the most horrifying memories
I will ever have.
Susan Da Silva lost her husband Dean
I know that they went through a horrible,
horrible experience.
And this was a violent end
these people suffered,
There were no bodies that were intact
or even close to intact
and they were conscious for a long time
before it all came apart.
Colleen Whirley died, along with her fiance Monty
As a mother,
keep waiting for her child to come home
And Colleen had travelled so much in her life.
it was unusual
not to have her just walking in the door
All this time you are thinking
something caused this,
something made this happen
And I want to find out:
Who is responsible for this?
Investigation into Alaska Airlines Flight 261
began to swing into gear
but the wreckage lay 700 ft down.
So NTSB officials called on NAVY submersibles
to retreat the plane from the seabed.
We set up the base of operations
The other ROV with the site-scanning sonar
which they use to map the debris-field
to get an idea of
how widely spread the wreckage was.
At the NTSB Headquarters in Washington
the investigator's immediate concern
was to find out what had brought the plane down.
The first clues came from the CVR
We immediately suspected
some problem in the tail of the airplane
which is where the controls are
Just something was wrong back there
That was the key piece of wreckage to look for.
The MD 83 that crashed was
a revised version of the Douglas Corporation's DC9
It was an extremely popular plane
Over 2000 were delivered to airlines worldwide
The engines were at the rear of the plane
and the distinctive T-shaped tail
was an essential element of the design.
In a big triple jet aircraft,
one of the rather brilliant elements of the design
is that, since you are going to
loading passengers and cargo,
you want to be able to have that aircraft loaded
a little nose heavier than a little tail heavy
In order to do that,
you have to have that entire stabilizer moving
but the most difficult thing to
engineer are the T-tailed airplanes
where you have the vertical stabilizer
and the horizontal sitting on top
and we call that: Stabilizer trim
and that is an essential element
of what makes these aircraft so useable
In the MD83, a motorized jack screw in the tail
moves the horizontal stabilizer up and down
As the stabilizer moves up,
the nose of the airplane moves down
As the stabilizer moves down
the nose of the airplane moves up
But what role had the 77cm long jack-screw played
in the loss of Flight 261?
The investigators were anxious to inspect it
as soon as it was recovered from the seabed.
The jack-screw wasn't mated with the nuts
that it screws in to
It was just by itself.
The nut was found in another piece of structure
a few feet away from where the jack-screw was.
To have a screw separated itself from a nut
with very thick threads
surprised us
Secondly,
we noticed that there was a curled
piece of rasp around the jack-screw
and all the threads that you can see here,
these ridges, were gone
They have been stripped out
and the remnants of those were found,
coiled on the jack-screw.
Once the thread had been stripped of the nut,
the jack-screw could no longer turn
The pilots could not have known
the real nature of the problem.
The crew was confronted with a situation
that had never occurred before.
There is no failed jack-screw procedure
In the QRH's that they have available
there is no training for it.
When the jack screw jammed,
the pilots were unable to adjust the stabilizer
We felt that it was due to the fact
that these nut-threads had worn away
and it was just too hard for that jack screw
under the power of the electric motor to turn
That gave the flight crew an indication
that there was a problem.
The crew knew they had a problem in the tailplane
but they had no idea what.
Two motors control the jack screw
and they tried each of them in turn.
But the pilot's attempts to free the stabilizer
made their situation worse
Where they went wrong was
that they wanted to try both the alternate
and the primary trim motors at the same time.
When the pilots switched both
the electrical motors on,
the jack screw moved
but the threads have given way
and the jack-screw was now held
only by a single retaining nut
From this point on, the plane was doomed.
That end nut was never designed to hold the loads,
generated aerodynamically by the tailplane.
Now we know, in the glaring light of hind-sights
now when turn the situation around in time
and look back
we can see that this
aircrew and no aircrew
should have been ever fooling with the trim
and trying to run it back and forth.
The retaining nut grew weaker and weaker
Then, finally
through a loads beating down on that nut
the nut finally failed
The jack-screw slid completely out of the nut,
allowing the horizontal stabilizer to
move well beyond its aerodynamic limits
The stabilizer forced the plane down
and is now completely out of control
it rolled over into its final dive.
This crew was working to recover the aircraft
right down to the water
They did not give up
the whole way down through the descend.
It was clear to the investigators
that the failure of the jack-screw
was the only explanation
for the erratic flightpath and final dive
But why had this happened?
Why had the jack-screw failed?
The investigators begin looking deeper and deeper
into the condition of the faulty jack screw
What had caused it to fail
There was no lubrication or visible grease
on the working area of the screw
That was surprising and strange.
The discovery of no grease on the jack-screw
alarmed the investigators.
They alerted the FAA
to order an immediate check
on all the MD 80s in the USA.
They made a shocking discovery.
At Alaska Airlines,
in 6 of its fleet of 34 planes,
the jack-screw assembly needed to be replaced
after failing new inspections.
No grease is the culprit
No grease or inadequate grease
is the only thing that can give you that wear
A simple lack of grease led to the failure of
a jack-screw and the loss of 88 lives
Why did this happen at Alaska Airlines?
The investigator's attention now switched
to the company's maintenance program.
What emerged, was deeply worrying
We interviewed all the mechanics
who had worked on these airplanes
We knew that they had been falsifying records
or not doing the work they had indicated
The mechanics at Alaska indicated that they were
pressured to keep the planes in the air
or that their recommendations were overruled
by supervisors.
Some alleged that records were altered to show:
WORK DONE that was not done
Alaska has long been one of America's
most successful airlines
but in the early 1990's
the economic downturn began
to hit the company hard.
Its response was to slash costs
to revive its fortunes.
Alaska Airlines began flying the planes
more intensively.
It sharply increased
the average daily use of its fleet
Keeping the planes in the air earning money
puts maintenance schedules under pressure.
John Liotine was a lead mechanic at Alaska
Airlines Oakland maintenance facility
where he worked for over 8 years.
Liotine felt that the new pressure on maintenance
put passengers' lives at risk
He was to paid dearly
for expressing those concerns
We have used an actor to portray his experiences
based on his sworn evidence to the NTSB.
Liotine claimed that planes were pushed back
into service too quickly.
Sometimes, rather than wait for
a replacement part or repair,
supervisors passed planes fit for service
free to carry passengers up into the air.
In October, 1998
over 15 Months before the crash
John Liotine became so worried
that he did something that
would chance his life forever.
He reported Alaska Airlines to the US FAA
alleging violations in maintenance procedures.
There were very few voices at Alaska
who had concerns about the maintenance
There should have been more and there should
have been people listening to John Leotine
He is a hero in my book.
In December 1999,
over a year before the crash,
The FAA and the department of transportation
officials moved on Alaska Airlines
The case was referred to federal prosecutors
and the FBI rated Alaska's maintenance facilities
and sees thousands of records.
The raid was the opening shot in the Federal Grand
Jury investigation that would last 3 years
No criminal charges were brought
against the company
Alaska Airlines officials deny that
any unsafe planes were put into service
or that passengers' lives were ever at risk.
But the investigation revealed
hundreds of violations of Federal regulations
Alaska Airlines was fined.
The FAA insisted on changes to the company's
maintenance and safety procedures.
The FAA also suspended two supervisors
for falsifying records.
Like other whistle-blowers,
John Liotine would pay heavily
for his efforts to save lives.
Alaska Airlines put him
on a paid leave from his job
costing him thousands of dollars
in regular overtime earnings.
Then, in January 2000,
John Liotine saw his worst nightmare come true
the kind of accident he had tried to prevent
by contacting the Federal Authorities
now took place,
just off the California coast.
After the crash of Flight 261,
John Liotine went back to his own work records
Incredibly, he found
that he had a direct link to the crashed airliner.
Over 2 years before at the plane's last overhaul
he had ordered the jack-screw on this
particular aircraft be replaced
He then went off shift.
When investigators examined the record
they found that Liotine's recommendations
had been overruled by the next shift
and the plane put back into service.
It would be 2,5 years before the next overhaul
but time ran out.
Two months before the overhaul was due
Flight 261 crashed.
Alaska Airlines labelled Liotine
at disruptive influence
Later, he sued the company for liable.
Alaska settled
but Liotine could no longer
work in the industry he loved.
I get calls on every week somebody saying
Should I blow the whistle?
And I always tell them
You need to know you need to be prepared
to find another line of work
because you will not work in the industry
and not in the government
In most cases,
it is almost impossible to be a whistle-blower
and to survive your career.
As the investigators continued their work
in Flight 261
they made another disturbing discovery
about the drive to cut costs at Alaska Airlines
To keep planes flying more intensively,
Alaska had dramatically extended
the intervals between service.
This was significant,
because when a plane is designed
every part has a scheduled listing
when it is serviced and when it must be replaced.
You supposed to go and inspect
in a every x hours
and that is different on parts
all over the plane
Some things you have to look at
after every flight
other things have to inspected every 2 or 3 days.
By 1996,
Alaska Airlines extended the intervals between
MD 83's jack-screw lubrications by 400%
Now, there was over 2,500 hours
between each service.
The extended service intervals would approve fatal
for Flight 261.
If you had 600 hours between
inspection points and greasing points
we have no chance of ever having
a metal to metal contact situation
but if you put that over 2000...2500 hours
now what you do is:
Eat in to some of these protective barriers
that we have towards catastrophic failure.
In its final report of
the crash of Flight 261
the NTSB concluded that Alaska Airlines' extended
service intervals for the jack-screws on its MD80s
was a significant contributor to the crash.
With harriers
doing everything to save a dime
maintenance, safety
And the shocking thing about Alaska is that they
were allowed to increase inspection intervals
It is shocking,
because that is the only way we have safety.
The extended maintenance intervals meant
that the lack of grease on the jack-screw
was not discovered before the crash.
But now, investigators wondered if the failure
of the jack-screw-assy
revealed a basic flaw in the plane's design.
They discovered that the MD 80 broke one of
the fundamental rules of aircraft design
It was not fail-safe
The design philosophy
that has made aviation so safe, is that
we should never have a situation in which
one catastrophic failure of some component
causes it to lose that airplane.
There was no back up
to the jack-screw and its nut.
Engineers never envisioned a situation
on the MD 80 where the jack-screw might fail.
With inspections every 600 flight hours
and replacement every 2000 hours,
the designers did not add
an additional redundant back up system.
It was utterly laughable
that they said it was a redundant system,
There is one screw and there is one nut
That is all there is; it is not redundant.
The MD 80 continues to fly worldwide
despite the revelation
of this potentially dangerous design flaw
the jack-screw assembly has not been redesigned.
Inspection intervals have been shortened
but airlines still rely on proper maintenance
to prevent the same accident happening again.
In its final report, the NTSB concluded
that the crash of flight 261
was due to the lack of adequate greasing
and the stretched service intervals.
When coupled with the design of the jack-screw
these failures led to
a completely avoidable accident
and the loss of 88 lives.
Three years after the crash
the relatives and friends of the dead
dedicated a permanent memorial
at port close Hueneme
close to the crash site.
I think the best thing and the only thing
in our infinite inadequacy
of making up for the loss of these lives
is to say something we've been able to say
in a lot of other accidents to grieving families,
and that is: those deaths will not be in vain
We will not let them be in vain
Every one of those lives will be made
to count in terms of making sure
that 3, 4, 5 or 10 people do not die.
Colleen was different,
she was adventurous
and there is nobody like that in our family.
I don't know what we can do
except to remember Colleen
and to live our lives now a little bit better
for her
When I was growing up
we didn't wear seat-belts
There weren't even seat-belts in cars.
Now we know that we need to wear seat-belts.
We didn't know much about smoking cigarettes
And now, we know that we can't smoke cigarettes
There is a lot to learn about airline safety, too
None of us is the same, anymore
It is like walking into a giant storm.
Wave after wave, forming up
coming in
because it never stops.
Grieve over the loss of a child is not something
I wish on anybody.
This plane went down because of neglect.
It seems like such an unholy type of loss
What a hard way to die,
so, an airline can...
...make more money.
Narrated by
Stephen Bogaert
Subtitles
Rein Croonen and transcript from the CVR.