Near-crash uncovers crack in air safety system By Alan Levin, USA TODAY For almost five years, one of the world's largest jetmakers knew that the=20 27-foot-tall tail fin on one of its jets had almost snapped off in flight.= =20 Officials with manufacturer Airbus understood that losing a tail fin would= =20 prove catastrophic. Even so, they kept their concerns to themselves until=20 after a tail fin did break off one of its jets, causing the second-worst=20 aviation disaster in U.S. history. Not until after American Airlines Flight= =20 587 crashed in 2001 =97 a catastrophe investigators say was caused when the= =20 tail fin broke off the A300 jet =97 did Airbus disclose its findings from an= =20 incident in 1997 to government safety officials, a USA TODAY investigation= =20 has found. Had federal regulators known earlier how easily tail fins could= =20 break in flight, the crash of Flight 587 =97 and the deaths of 265 people = =97=20 might have been prevented, according to some accident investigators and=20 aviation safety experts. The jet crashed Nov. 12, 2001, just after takeoff= =20 from New York's John F. Kennedy International Airport. The nation's=20 aviation safety system is designed to prevent crashes by learning lessons=20 from close calls. In this case, the system broke down. "When I heard (about= =20 what Airbus knew), it made me sick," says Bernard Loeb, who headed the=20 National Transportation Safety Board's (NTSB) aviation division until=20 January 2001. "People are kicking themselves." The system is dependent on airlines and jetmakers sharing their knowledge=20 and experience with federal regulators. The NTSB, an agency with limited=20 resources, cannot function without this help, current and former=20 investigators agree. But those are the very entities the NTSB investigates.= =20 Airbus officials say they did nothing wrong. They say that the crash of=20 Flight 587 was due to mistakes by the pilots and that there is nothing they= =20 could have done to prevent it. Attempts to find fault with the company are= =20 "projected wisdom in hindsight," spokesman Clay McConnell says. USA TODAY=20 reviewed hundreds of pages of NTSB documents and interviewed more than a=20 dozen government officials and knowledgeable sources. The review found that= =20 on May 12, 1997, American Airlines pilots on Flight 903 from Boston to=20 Miami lost control of the jet. In response, they made a series of radical=20 maneuvers that placed extreme stress on the tail fin, nearly snapping it=20 off. Eventually, they landed safely. Within days, federal investigators=20 knew that the jet had nearly crashed, but they did not realize how close it= =20 came to breaking apart in midair. Then last year, a closer examination of=20 the tail revealed that it had cracked during the incident. If federal=20 regulators had known this information, they say, they could have warned=20 pilots to avoid the nearly identical maneuvers that caused the crash two=20 years ago. It's impossible to know for certain whether a more thorough investigation=20 in 1997 could have prevented the 2001 crash, several senior investigators=20 say. Those officials still do not know why the co-pilot aboard Flight 587,= =20 leaving New York for the Dominican Republic, suddenly began his maneuvers.= =20 A final report on the accident is expected early next year. Even so, said=20 NTSB board member Carol Carmody, "It's enormously frustrating that we=20 didn't have this information." Carmody was acting chairwoman of the agency= =20 when Airbus revealed its findings last fall. "I feel that we missed an=20 opportunity," she said in an interview. The stakes are also enormous in=20 lawsuits stemming from the 2001 crash. Airbus and American Airlines are=20 battling over who should pay damages for the crash. The close call Flight 903 from Boston had been routine, if a little bumpy. The pilots,=20 waiting for storms over Miami to clear, reminded passengers to buckle their= =20 seatbelts. Controllers ordered them to hold at 16,000 feet near West Palm=20 Beach. At 3:29:14 p.m. May 12, 1997, as the jet began a turn, it suddenly=20 banked hard to the right, back to the left, then to the right again. "It was horrifying," Michelle Singh, 36, who was seated in row 16, recalled= =20 in an interview. "There were no words to explain. People crying. People=20 hurt. People scared. I was ready to die." Passengers clung to each other as= =20 the gyrations tossed them from side to side. Anything not strapped down =97= =20 shoes, briefcases and passengers themselves =97 flew about the cabin,=20 according to NTSB records. After 12 seconds, the jet began to plunge. It=20 fell 3,000 feet in 18 seconds. Melanie Joison's baby flew out of her arms.= =20 Joison unbuckled her belt to grab her baby and crashed face-first into the= =20 ceiling. The blow knocked her unconscious and broke four of her ribs. Other= =20 passengers safely caught the baby. "The terror and the screams were more=20 than I have ever experienced," Scott Stow, an American pilot sitting in the= =20 passenger section, told investigators then. Capt. Mark Eberle and co-pilot Donald Rescigno told investigators it seemed= =20 that a mysterious force =97 perhaps a powerful downdraft =97 had blown the= jet=20 out of control. Initially, the jet banked 56 degrees to the right =97 twice= =20 as steep as a passenger jet ever gets in a normal flight. The co-pilot=20 tried to level the jet with the control wheel, which activates panels on=20 the wings. It had no effect. Rescigno tried the rudder, a large vertical=20 panel at the rear of the tail fin. His left foot stomped on one of two=20 pedals that move the panel. The rudder swung left. A jet's rudder has=20 tremendous power. It keeps the jet flying straight if one of the two=20 engines fails. The control wheel, which looks similar to a car's steering=20 wheel, is the preferred way to level a jet's wings, but the rudder=20 accomplishes the same thing in a clumsy, overpowering way. Rescigno held=20 the rudder pedal down for four seconds. By then, the jet was rolling back=20 to the left so quickly he could not control it. The left wing dropped=20 sharply. Rescigno responded by slamming on the right rudder pedal, which=20 began the cycle again. The jet banked back to the right even more steeply,= =20 to 65 degrees. Overall, the jet banked left or right nine times within 40 seconds. In the= =20 most severe bank, the jet tilted at 83 degrees =97 its right wing pointed=20 nearly at the ground. Eventually, the pilots increased the speed of the jet= =20 enough to regain control. Thirty minutes later, the jet landed in Miami,=20 the cabin a mess of upended food carts, luggage and trembling passengers.=20 The pilots' rudder movements were nearly identical to those on Flight 587.= =20 The co-pilot on the later flight whipped the jet's rudder left or right=20 five times. On its last swing, the tail fin snapped off the fuselage. Pilots caused 'stall' Soon after Flight 903, NTSB investigators discovered that the incident had= =20 little to do with a gust of wind. The pilots had made a series of errors=20 that caused the wild ride. The pilots allowed the jet to slow too much as=20 it entered the holding pattern, the jet's data recorder showed. The pilots= =20 apparently put the engines in idle as they descended and neglected to add=20 power after leveling off at 16,000 feet. As a result, the jet essentially=20 stopped flying, a condition known as a "stall." When the pilots began the=20 initial bank to the right, the stall caused the right wing to drop more=20 than the pilots intended. The discovery that pilots could forget to maintain enough speed disturbed=20 the NTSB. The agency focused on that failing as the central problem. A yearlong probe began. Federal investigators had no idea that within a month of the incident,=20 Airbus engineers in Europe found an additional problem: The jet's gyrations= =20 had put massive strain on the tail fin. In an internal memo on June 12,=20 1997, an unidentified Airbus official wrote that his department "urgently"= =20 recommended additional inspections of the jet because the forces on it had= =20 apparently exceeded the "design limit." That meant that the wind and=20 jostling on the tail fin had exceeded the greatest forces it had been=20 expected to experience in its lifetime. Then, on June 19, a more complete=20 analysis showed that the forces not only had gone above the design limit,=20 they also apparently had reached the "ultimate limit." When engineers build= =20 a jet, they compute the greatest forces likely to hit surfaces, such as=20 wings and the tail. These are known as design limits. For a safety margin,= =20 international aviation regulations mandate that they make those surfaces=20 50% stronger. These are the ultimate limits, above which a tail fin or=20 other surface is expected to fail. It's extremely rare for commercial aircraft to reach a design limit in=20 flight. It's almost unheard of for one to reach an ultimate limit. That=20 would mean it had come dangerously close to breaking apart. Such a finding= =20 would get immediate attention from federal investigators =97 if they learn= =20 about it. Had Airbus pressed the matter in 1997, its findings would have=20 been worse. Flight 903's tail fin reached or exceeded its ultimate limit=20 three times during the incident, Airbus itself calculated last year. A=20 Federal Aviation Administration official testified at an NTSB hearing in=20 October that a conservative estimate found the stress on the tail fin went= =20 well above the ultimate limit =97 to within 1% of the force required to= break=20 it off. In June 1997, Airbus requested that American Airlines perform=20 another inspection of the jet to ensure it was not damaged. American=20 inspectors, following Airbus' instructions, examined the tail fin. But they= =20 did not use methods that would have allowed them to see inside the tail=20 fin. They saw no damage from their visual inspection, and the jet continued= =20 to fly for nearly five years. Only last March, as part of the Flight 587=20 investigation, did Airbus conduct an ultrasound inspection of the tail fin= =20 on the jet involved in the 1997 incident. The inspection found two=20 crescent-shaped cracks at one of the points where the tail fin attaches to= =20 the fuselage. The fin was replaced. Airbus says the tail fin was still=20 strong enough to meet regulatory requirements. Airbus engineers weren't the only ones who expressed worries about the=20 incident. A high-ranking American Airlines pilot wrote a memo to a senior=20 official in May 1997 warning that the pilots' use of rudder had nearly=20 caused major structural damage to the jet. Paul Railsback, flight=20 operations managing director, urged immediate changes in American's pilot=20 training, says the memo obtained by USA TODAY. Again, the NTSB has no=20 record that Railsback's concerns were brought to its attention. American=20 says it altered its training to reflect his comments. Airbus' response Airbus officials deny withholding data or hindering the probe of Flight=20 903. "I am convinced that my company made a good faith effort to raise=20 these concerns," says McConnell, Airbus' spokesman. Officials also say they= =20 did not realize that the tail fin on the jet had nearly broken loose. In=20 part, that's because Airbus built the tail fin 25% stronger than=20 regulations required. By insisting on an additional inspection of the tail,= =20 Airbus felt confident that it had not been damaged, McConnell says.=20 Furthermore, he says, the 1997 assessments were imprecise and Airbus did=20 not calculate the actual stress on the tail until last year. The NTSB and=20 American had access to the same data and failed to raise concerns, he says.= =20 At the NTSB hearing in October on Flight 587, an American Airlines official= =20 was permitted to put questions to Airbus officials. With the two firms=20 feuding over who is at fault in the 2001 crash, the questioning quickly=20 grew tense. Airbus' Michel Curbillon said the company had shared its=20 concerns about Flight 903 with federal investigators and others. "This has= =20 been known within the company and was also informed to everybody,"=20 Curbillon said. His questioner, American's Tim Ahern, who had worked on the= =20 Flight 903 investigation, disputed him. "Frankly, as a party to that event,= =20 sir, this information was just (released) this year," Ahern said. Curbillon pointed to a report submitted to the NTSB in August 1998, on the= =20 Flight 903 investigation. Airbus' flight safety director, Yves Benoist,=20 wrote that pilots needed to be trained better on how to use the rudder.=20 "Using too much rudder in a recovery attempt can lead to structural loads=20 that exceed the design strength of the fin," the report said. Airbus=20 officials say they underscored their concerns in 1997 by raising repeatedly= =20 the broader issue of pilot training on rudder use. For example, an August=20 1997 letter sent to American and written by Airbus, Boeing and the FAA=20 warned that pilots could damage a jet with too much rudder. But the NTSB=20 has no record that Airbus disclosed what it had learned about the stress=20 put on Flight 903's tail fin. The submission to the NTSB contained only a=20 general warning about rudder use. The letter to American did not mention=20 Flight 903 and was not sent to the NTSB until last year. NTSB and American= =20 officials say the Airbus warnings were so vague that they did not attract=20 attention in the Flight 903 probe. When Loeb, who has retired from the NTSB, learned in October that Airbus=20 knew in 1997 about the high stress on Flight 903, he was dumbstruck. He had= =20 overseen the earlier investigation and never heard a word about the high=20 stress on the tail fin, he says. Even if the calculations were preliminary,= =20 Airbus had a duty to share them, he says. "That's a significant,=20 significant issue," Loeb says. The jet involved in the incident should have= =20 been grounded until regulators were certain it was not damaged by the=20 extreme forces, he says. Officials who were part of the probe in 1997 say= =20 if they had known of Airbus' findings and the damage to the fin, it would=20 have changed the focus of the investigation. Rather than focusing on the=20 pilots' actions, the NTSB would have looked more closely at the rudder=20 itself, they say. "I think the answer is most assuredly we would have done= =20 something more on 903 if we had known this, if we had heard this from=20 Airbus," the NTSB's Carmody says. What about safety board? Among the small circle of senior accident investigators, there is also=20 debate about whether the NTSB itself should have seen the clues back in=20 1997 that rudder use could damage a tail fin. According to former NTSB=20 chairman James Burnett, the answer is yes. The agency's job is to turn the= =20 jumble of aviation incidents into nuggets of common sense that prevent=20 accidents. By definition, it should have unraveled the puzzle and acted,=20 Burnett says. But, with only 60 aviation accident investigators and=20 engineers to work cases involving airlines, it does not surprise him that=20 the NTSB occasionally misses things. This is especially true during busy=20 periods such as 1997, when the board was occupied with two crashes that had= =20 occurred the prior year: TWA Flight 800 and the ValuJet crash in the=20 Florida Everglades. "But it should be an occasion for taking stock,"=20 Burnett says. Such concerns are not new. A Rand Corp. report in 1999 warned= =20 that the agency was too dependent on the airlines and aircraft=20 manufacturers it investigates. The report urged greater use of independent= =20 experts to supplement NTSB investigations. Loeb says he wishes now that, in the midst of perhaps the busiest period in= =20 the agency's history, he had spent more time on Flight 903. "People are=20 saying, 'We should have done more.' But the fact is, these are people who=20 are working 60 hours, 70 hours a week and getting paid for 45 or 50. Yeah,= =20 they are going to miss things and feel bad about it," he says. "On the=20 other hand," Loeb adds, "if Airbus did the calculations and didn't bother=20 to tell us, shame on them." *************************************************** The owner of Roger's Trinbago Site/TnTisland.com Roj (Roger James) escape email mailto:ejames@xxxxxxxxx Trinbago site: www.tntisland.com Carib Brass Ctn site www.tntisland.com/caribbeanbrassconnection/ Steel Expressions www.mts.net/~ejames/se/ Mas Site: www.tntisland.com/tntrecords/mas2003/ Site of the Week: http://www.caribbeanfloral.com TnT Webdirectory: http://search.co.tt *********************************************************