Exactly one month into the new millennium, Alaska Air flight 261 crashed into the Pacific Ocean off the coast of Los Angeles. It was a scheduled international flight from Puerto Vallarta, Mexico, to Seattle-Tacoma Airport in Washington. There were two pilots, three cabin crew members and 83 passengers on board. There were no survivors.
The primary cause of the accident was the failure of a jackscrew nut, which controlled the pitch trim for the MD-83 aircraft. Ultimately investigators would be convinced that the jackscrew in question had not been greased during at least two consecutive maintenance events. The NTSB would also fault significantly extended maintenance intervals on the jackscrew (which had been increased from 500 hours to 2,550 hours over an eight-year period), and point the finger at the FAA for lax oversight of Alaska Airline’s maintenance procedures.
A common trait in effective leaders is the ability to be decisive. Imperfect decisions made decisively almost always produce better results.
These two issues would be joined by a third: End play checks indicated unusually rapid wear to the accident aircraft’s jackscrew more than a year prior to the crash. The mechanic who performed the end play check stated that he had never witnessed a jackscrew in such a worn state. As a result, he submitted a work order to replace the component. This was where – a year later – the NTSB would become perturbed with Alaska Airlines. A graveyard shift mechanic would cross out the work order to replace the jackscrew and instead remeasure the end play five separate times to verify it was within minimum wear limits (it had .007 inches to spare). The aircraft was unceremoniously returned to service.
Only a Matter of Time
Hidden in the tail of the aircraft was a rather large screw spinning through an unlubricated nut. Every second of horizontal trim chafed another millionth of an inch of thread. By the time of the accident, the pitch trim system had been a ticking time bomb for weeks. The initial failure occurred in the climb with the autopilot on. Eventually, elevator forces would cause the autopilot to disconnect. The crew would continue the climb for the next seven minutes through sheer endurance – up to 50 pounds of elevator force was required to maintain pitch attitude.
The cockpit voice recorder only captured the final 31 minutes of the flight, so there is no record of what the crew was doing while they were over Mexico. Undoubtedly, they ran the “Stabilizer Inoperative” checklist. They paused at an intermediate altitude for crossing traffic. Once they leveled off at 31,000 feet, the pulling force on the flight controls decreased to 30 pounds. Eventually, the crew sorted out that they could reduce the control forces if they increased airspeed. The aircraft subsequently accelerated from 280 KIAS to 301 KIAS, and the control force decreased to 10 pounds. The Stabilizer Inoperative checklist did not explicitly direct the crew to land at the nearest suitable airport, and so the flight continued for the next two hours towards Southern California.
It is easy to sift decisions through the hindsight of tragic fatalities. It is obvious now that an immediate return to Puerto Vallarta would have greatly increased the chances of a safe landing. For every second that the crew failed to make a decision, Los Angeles beckoned (there are very few landing alternates between Puerto Vallarta and LA). Flying in international airspace produces a complexity for an aircrew in a stressful situation. The California coast likely brought great comfort.
The cockpit voice recorder begins in the middle of a conversation between the captain of Flight 261 and Alaska Airlines maintenance controllers in Seattle. Within the first minute, a mechanic queries the captain, “Understand you’re requesting diversion to LA…is there a specific reason you prefer LA over San Francisco?”
This was a question with in-between-the-lines implications. Alaska Airlines 261 was originally scheduled from Puerto Vallarta to Seattle with a scheduled stop in San Francisco. The mechanic was advocating the captain to continue the flight to its intermediate destination. The captain would haltingly equivocate that he favored the weather in LA. He would later admit that he was concerned about the ability to safely land the aircraft: “I’m concerned about overflying suitable airports.”
The maintenance controller would not give up: “[Will the] added fuel that you’re gonna have in LA be a complication or an advantage?” This point actually had some merit. A lighter aircraft is generally preferable for an abnormal landing. Burning off fuel was already reducing the amount of control force that the crew was encountering (the crew had reselected the autopilot on as a result – even though this was contrary to guidance found in the Stabilizer Inoperative checklist). In truth, the destination was not going to have a direct bearing on the final outcome of the flight.
The flight’s dispatcher would immediately apply additional pressure: “If we land in LA, we’ll be looking at probably…an hour and a half [delay, ATC has] a major flow program going…in San Francisco.” The captain would feebly respond: “Boy…you put me in a spot here.” Airline personnel at LAX would pile on: “Be advised we have to get landing rights…I have to clear it all through customs first.” The captain responded more assertively: “Better start that ‘cause we are coming to you.”
A few minutes later, the captain requested an update on San Francisco weather, clearly succumbing to a bout of second-guessing. A station mechanic at LAX would contact the crew asking, “Did you try the suitcase handle and the pickle switches?” Suitcase handle was a colloquialism for a mechanism on the pedestal that commanded the electric trim motor. Pickle switches performed the same function on the yoke. The mechanic was wondering if a switch had failed.
The captain told the mechanic: “[Pitch trim] appears to be jammed…the whole thing.” This innocuous exchange would result in a befuddling sequence of events. Without communicating with the first officer (who was the pilot flying), the captain apparently decided to try the trim one last time. The only record of this moment – which occurred four seconds following his conversation with the LAX mechanic – was the captain muttering (apparently to himself): “Let’s do that.” This was followed by the sound of a click, then a clunk, then two faint thumps, and then an expletive as the aircraft pitched aggressively down. The first officer would ask in alarm, “What are you doing?”
In the following two minutes, the aircraft descended from 31,000 feet to 23,000 feet. Twenty-five seconds after the dive began, the captain informed ATC, “We’ve lost vertical control of our airplane.” There was limited communication with ATC for the next minute. It is likely that the controller identified Flight 261 as an emergency aircraft at this point. Only once in the transcript does the crew explicitly declare an emergency – and it was the first officer, one minute prior to the crash, who exclaimed, “Mayday” (he never actually transmitted the phrase over the radio – it was captured on internal microphones).
The aircraft would recover for several minutes at 24,000 feet. The threads in the jackscrew nut had completely failed, resulting in the horizontal stabilizer moving to its nose-down mechanical stop (the nut threads would later be found tangled around the jackscrew). The crew managed to maintain basic control for the next nine minutes. During this period, the captain once again communicated with a mechanic on the ground at LAX, explaining that the trim had ran away full nose down. The mechanic inquired as to whether the crew had attempted to trim the nose back to a neutral state. The captain responded: “I’m afraid to try it again…”
Thirty seconds later, the captain asked the first officer, “You wanna try [the trim] or not?” The first officer responded: “Boy, I don’t know.” The captain would demure: “It’s up to you, man.” The first officer suggested proceeding to LAX. He also suggested briefing the passengers. The captain would do so and then descend once again, this time intentionally.
The captain decided to test the flaps at 17,000 feet. He noted that the configuration helped stabilize the aircraft. Then – for unknown reasons – he directed that the flaps be retracted again. The aircraft accelerated from 248 knots to 270 knots following retraction and once again became difficult to control. A minute later, the CVR recorded a sound similar to the movement of the slat/flap handle. Four seconds later, the aircraft would enter its final, fatal dive. The horizontal stabilizer, abnormally stressed due to elevator loads (exacerbated by the second selection of flaps at relatively high speed), finally failed completely – the structure connecting it to the vertical spar crumpled, resulting in an uncontrollable condition.
The captain’s flying skills would prove unusually sharp at this point. Recognizing the danger of the nose down pitch, he would apparently decide to roll the aircraft inverted. He would exclaim: “Push and roll, push and roll. Ok, we are inverted…at least upside down, we’re flying.”
The aircraft was doomed at this point. The elevator did not have the control authority needed to compensate for the failed horizontal stabilizer. Compressor stalls were soon heard on the CVR due to the negative angle of attack on the inverted engines. Just before impact, the captain uttered his final words: “Ah, here we go.” Unquestionably this comment was made by an individual who knew that he was about to die. The captain never gave up, fighting to the very end. His final moments proved to be ones of courage.
The NTSB blamed the crash on a combination of Alaska Airlines maintenance and insufficient FAA oversight (Alaska Airlines has maintained an impeccable safety record since). The accident report notes the catastrophic failure of a jackscrew was an abnormality for which the crew had no training or experience to assist in their decision-making efforts. It would be unfair to blame the crew for their confused response to a befuddling mechanical failure. Still, there are lessons to be learned here.
Within sight of Los Angeles, the captain became stuck in a neverland between the desire to maintain the schedule and the gnawing concern that something very serious was wrong. In the midst of this he briefly abdicated his command authority. His initial decision to execute a precautionary landing at LAX was unambiguous, yet he apparently became persuaded by outside sources to attempt to salvage the flight. It is easy to understand the desire to be a team player and instructive to qualify when that desire should be cast off.
The fact that the captain was concerned enough regarding the aircraft’s handling characteristics to prefer the runway at LAX was a clear indication that a critical state existed. The fact that he had flown for a couple of hours in that condition likely made him reluctant to declare an emergency once he was with Los Angeles controllers, but it was the proper course of action to take. His failure to unequivocally declare an emergency produced a blasé response from personnel on the ground, and it was this blasé response that ultimately incited the final, deadly decision.
The declaration of an emergency is not an admission of failure. It merely informs air traffic control that an aircraft requires priority handling. It also puts the pilot in a mental state where their focus can shift from the mission (getting to the destination) to executing a safe landing. Lingering uncertainties will collapse, and the focus of all the available resources can be directed towards a safe resolution to the crisis.
A common trait in effective leaders is the ability to be decisive. This is true in nearly any endeavor – flying an airplane, running a business, or raising a family. Command authority does not exist for the sake of hubris: it exists to eliminate useless committee deadlock. Consensus building has its place, but it also has its dangers. Imperfect decisions made decisively almost always produce better results. Perfection is impossible, chasing after it pointless – particularly when lives are hanging in the balance.