NTSB hits Alaska's maintenance 'culture' in Flight 261 report

The National Transportation Safety Board yesterday issued a scathing final report on the crash of Alaska Airlines Flight 261 in January 2000, saying safety breakdowns at Alaska that led to the accident were "less coincidence than culture."

"Alaska needs to re-constitute its will to performance and perfection on the shop floor," board member John Goglia wrote in a 235-page report detailing broad findings approved by the board during a public meeting last month.

The board's three other members concurred with his statement and, in a separate statement, said the Federal Aviation Administration should strongly consider taking a new look at Alaska in light of continuing concerns about its maintenance programs.

Although he said NTSB maintenance recommendations should prevent another Flight 261-type crash, Goglia, a former airline mechanic, wrote that "maintenance, poorly done, will find a way to bite somewhere else."

No comment from Alaska

Alaska did not respond yesterday to a request to comment on the report. The carrier has said it has overhauled its maintenance operations since the crash and contends its maintenance is now among the best in the industry.

All 88 passengers and crew members on Flight 261 were killed Jan. 31, 2000, when the MD-83 plunged into the Pacific Ocean off Southern California.

Federal prosecutors in San Francisco, who announced in December 2001 they had not found criminal wrongdoing in the crash, plan to closely review the NTSB report to see if the investigation should be reopened, according to law-enforcement officials, speaking on condition of anonymity.

More information The NTSB Flight 261 site The NTSB Executive Summary on the Flight 261 crash The complete NTSB report (2.4M PDF) Flight 261: A seattletimes.com story archive For an NTSB animated reconstruction of the accident, go to the agency's Flight 261 Presentations page and click on "Animation" (1M Windows Media file)

The U.S. Attorney's Office in San Francisco declined comment, but it previously has said it would examine the findings. Family members of those killed in the crash are pressing prosecutors to reopen the case.

In reaching its findings, the safety board said it still questions the "depth and effectiveness" of Alaska's actions to correct maintenance problems since the crash and "remains concerned about the overall adequacy of Alaska Airlines' maintenance program."

Those comments represent a stronger stance than the board took when it held its public meeting Dec. 10 to preliminarily announce its findings.

At that time, the board rejected a formal recommendation from its staff to urge the FAA to conduct a top-level inspection of the airline, as the FAA conducted three months after the crash, when it found serious deficiencies in Alaska's maintenance practices.

Yesterday, the board didn't alter its conclusion, which was based on Goglia's concern that the FAA needed to concentrate its resources on the troubled airline industry. But the three members other than Goglia said the FAA needs to carefully review whether it should take another look at Alaska.

"The argument made during the meeting that yet another inspection of Alaska Airlines would divert already stretched FAA resources is actually an argument for the FAA to make," acting Chairwoman Carol Carmody said in a statement joined by board members John Hammerschmidt and George Black.

"There needs to be an assurance that Alaska Airlines has permanently remedied the recurring maintenance problems we have documented in our exhaustive investigation," Carmody wrote. "The public expects and deserves no less."

Her statement said the FAA "should not have to be coaxed by the NTSB into being more proactive, and I hope we have not served to perpetuate any problems at Alaska Airlines that the recommended inspection was intended to identify and correct."

FAA spokesman Laura Brown in Washington, D.C., said the agency would study Carmody's statement, along with other recommendations made by the board, and respond within 90 days.

The board's report reiterated the central finding of the Dec. 10 meeting, in which it blamed Alaska for the crash, finding that a key flight-control component in the plane's tail section was insufficiently lubricated.

As it did at the Dec. 10 meeting, the board also faulted the FAA for failing to properly oversee the carrier, concluding that Alaska, while increasing its flight hours, was allowed to extend maintenance intervals for lubricating and checking wear on the component without proper analysis.

Also contributing to the accident was the lack of a fail-safe mechanism on the McDonnell Douglas-built jet to prevent the catastrophic failure of the component, the board found.

The component that failed — the jackscrew assembly — is a 2-foot-long, 1½-inch-diameter threaded shaft that moves up and down, raising and lowering the leading edge of the horizontal stabilizer, the winglike structure on the tail that controls the plane's pitch.

Investigators were unable to find any grease in the jackscrew's acme nut or the working areas of the screw itself.

In addition, the passageway where grease is squirted into the nut with a pressurized gun contained a "dried, claylike substance consistent with degraded grease" when it should have contained fresh grease, the board said in yesterday's report.

The board said interviews with the Alaska mechanic who performed the last lubrication before the crash, in September 1999, "revealed his lack of knowledge about how to properly perform the procedure." The mechanic said he did not recall checking to see if grease was coming out of the top of the nut, as specified in lubrication guidelines, the board said.

"Woefully executed"

"This is a maintenance accident," Goglia said in his statement, declaring that Alaska's maintenance and inspection of the horizontal stabilizer were "poorly conceived and woefully executed."

Goglia also cited the last major maintenance check of the plane in September 1997. During that check, a senior Alaska mechanic found that the jackscrew should be replaced because it had reached the highest limit of its allowable wear, though automatic replacement wasn't required. Other mechanics, facing a nearing deadline to complete the check, performed a new wear test and found the part to be within its limit. Alaska didn't have another jackscrew in stock at the time and never ordered one in response to the original replacement request.

Goglia, in his statement, said mechanics "found a jackscrew that needed to be pulled, but no spare was found, and as the part was arguably acceptable, they pushed the plane back into service, with no watch list, no trailers, or orders to keep track of its condition."

The plane was technically legal and safe if had been carefully greased, Goglia wrote, but it "was not, we know that without question." In fact, Goglia said, the plane was released with a jackscrew of "questionable serviceability that was, in all probability, not greased."

"And the evidence is that it was never adequately greased again," he wrote. "Had any of the managers, mechanics, inspectors, supervisors, or FAA overseers whose job it was to protect this mechanism done their job conscientiously, this accident cannot happen."

Additionally, Goglia said, Alaska's ground personnel seemed to have pushed the two pilots to continue to San Francisco with a "broken plane" when they reported problems. He said no one will ever know if they did so to ensure the convenience of passengers and maintenance.

"But the impression is inescapable. An aircraft that had been hustled out the door three years earlier for the convenience of scheduling was now encouraged to keep to its appointed routing. It is less coincidence than culture."

Steve Miletich: 464-3302 or smiletich@seattletimes.com.