[27], In 1998, an Alaska Airlines mechanic named John Liotine, who worked in the Alaska Airlines maintenance center in Oakland, California, told the FAA that supervisors were approving records of maintenance that they were not allowed to approve or that indicated work had been completed when, in fact, it had not. All rights reserved. The turn of the millennium had just come and gone, and the future again seemed limitless. Following the crash and the damning FAA special inspection report, Alaska Airlines overhauled its maintenance program, including through its compliance with a new FAA airworthiness directive mandating that the jackscrew lubrication interval not exceed 650 flight hours. Neither the flight crew nor company maintenance could determine the cause of the jam. During the course of the investigation and in its final report, the NTSB issued a large number of recommendations, including that the lubrication procedure for the MD-80 series jackscrew be revised; that a more accurate method of measuring wear on the jackscrew be developed; that maintenance technicians be specifically taught how to grease and inspect jackscrews; that the FAA not approve lubrication interval extensions without the airline providing supporting data; that all airlines be surveyed to ensure compliance with jackscrew lubrication procedures; that a bulletin be issued instructing pilots not to troubleshoot inoperative flight controls; that maintenance personnel and dispatchers be trained not to suggest continuation of a flight that is experiencing a major malfunction; that the jackscrew be made easier for maintenance workers to access; that an inspector be required to sign off on every lubrication of the jackscrew; that all maintenance intervals for critical components be re-examined based on data analysis to ensure that they are not too long; that the application process for maintenance interval changes be reformed; that MD-80 series jackscrew inspections be made on a tighter schedule; that some failsafe mechanism be incorporated to ensure the redundancy of the MD-80 jackscrew; and that the FAA ensure future stabilizer designs cant have a single point of failure. Push and roll! Thompson shouted, trying to coordinate with Tansky to roll the plane right-side-up. The airline ended up being fined a mere $44,000 for allowing planes to fly 840 times without properly completed maintenance records. But airline dispatchers in Seattle were less keen on this idea and preferred that flight 261 continue to San Francisco as scheduled. This caused the stabilizer to pivot upward, thus causing the airplane to pitch down and enter the initial dive (see graphic 7). Not according to that its not, said Tansky. N963AS, the plane that would later become Alaska Airlines flight 261, was one of many in the airlines fleet that was subject to these marginal maintenance practices. Both of these circumstances resulted from Alaska Airlines' attempts to cut costs. [6] The captain then replied "ok right rudderright rudder," followed 18 seconds later by "gotta get it over againat least upside down we're flying. Different speeds and phases of flight require the stabilizer to apply varying amounts of downforce on the tail in order to keep the plane level, and further adjustments must be made to ensure that the pilots dont have to continuously pull up or push down using the elevators in order to climb or descend. Pilots of nearby planes caught sight of flight 261 and radioed Los Angeles air traffic control. The CEO of Alaska Airlines, Brad Tilden, joined them and read a public apology to the families on behalf of the airline. As then-Board Member John Goglia wrote in the NTSB final report, This was a maintenance accidentmore pure than any others.. Saudi Arabian Airlines Flight 763/Kazakhstan Airlines Flight 1907 Crash Documentary - Sigh. The probable cause was stated to be "a loss of airplane pitch control resulting from the in-flight failure of the horizontal stabilizer trim system jackscrew assembly's trapezoidal nut threads. This interval was increased again in April 1996 to 30 months equating to about 9,550 flight hours under the airlines accelerated utilization. In the ten minutes that had passed since the dive, the stabilizer had been held at 3.1 degrees nose down by nothing more than the mechanical stop on the bottom of the jackscrew. The FAAs special inspection report noted that the position of Director of Maintenance had gone unfilled since 1998; the Director of Operations position was empty; the Director of Safety was also the Director of Quality Control and the Director of Training and didnt report to high-level management; there was no maintenance training curriculum; on-the-job training was completely unstructured; the procedures in use didnt match those outlined in the maintenance manual; planes had been released from C-checks with paperwork incomplete; perishable and consumable materials had expired; shift turnover paperwork was missing, unsigned, or incomplete; work cards were not filled out properly; and more the list went on and on. On January 31, 2000, Alaska Airlines Flight 261, bound for Seattle, plunges into the Pacific Ocean 40 miles northwest of Los Angeles, off the coast of California, killing all 88 passengers and crew. Did it happen went in reverse? Tansky asked. It was found that the use of Aeroshell 33 was not a factor in this accident. Mechanical stops attached to the jackscrew prevent the stabilizer from moving farther than 2.5 degrees upward or 12.5 degrees downward. It forced us to be betterwe will always work to hold our company to the highest standard of safetyas a legacy to those who lost their lives. A few days before the gathering, Alaska was rated as the safest major airline in the U.S. by AirlinesRatings. The green grease did appear to be more wet to me. Nine years after the cost-cutting began, Alaska Airlines was posting profits again, its fleet was expanding, and passenger numbers were higher than ever. Speedbrakes! Captain Thompson called out, still trying to find ways to arrest the dive. Key safety-related positions within the airlines management structure went unfilled. [6] The accident showed that certain wear mechanisms could affect both sets of threads and that the wear might not be detected. They sounded experienced, calm and professional. This three-dimensional animated accident reconstruction shows the final pitch-over and initial portion of the dive for Alaska Airlines Flight 261, which cras. Captain Thompson was not happy with this reasoning. This Episode we take a look at a very preventable accident from January 2000, where an Alaska Airlines MD-80 lost all control of a vital mechanism used in ba. And while the airline did eventually settle the suits, it did so only after dragging the families through what many described as a legal hell in which Alaskas lawyers tried to downplay the monetary value of their deceased loved ones. Many did not apply grease to the entire length of the jackscrew as per the procedure. Nine days after the accident, the first major piece of wreckage recovered was the horizontal stabilizer by Portland car accident lawyers. In 1996, Alaska Airlines applied to the FAA to extend the interval between its C-checks from 13 months to 15 months. Alaska Airlines now flies from Puerto VallartaSeattle/Tacoma nonstop with Flight 127 and Puerto VallartaSan Francisco nonstop with Flight 1273. As any good crew should do, Thompson and Tansky then pulled out the checklists for a runaway or inoperative stabilizer. FAA employees charged with overseeing safety compliance at Alaska before the crash complained that they did not have sufficient staff to closely track its operations, which doubtlessly contributed to the airlines ability to keep woefully deficient maintenance practices under the radar of the federal government. An FAA inspector who reviewed the 1996 extension said that the airline presented only Boeings recently extended lube interval as justification. Both pilots struggled together to regain control of the aircraft, and only by pulling with 130 to 140 lb (580 to 620 N) on the controls did the flight crew stop the 6,000ft/min (1,800m/min) descent of the aircraft and stabilize the MD-83 at roughly 24,400ft (7,400m). The data indicated that the airplane climbed normally until 23,400 feet, where the horizontal stabilizer trim system stopped moving, the autopilot disconnected and the climb rate slowed. Individual maintenance tasks (such as the end-play check) were not separately considered in this extension. A cacophony of banging and roaring filled the cockpit. In September 2000, he filed a $20 million libel lawsuit against Alaska Airlines, arguing that he had been right all along and that Alaska had maliciously harmed his reputation. With no grease at all, the rate of wear would increase by a factor of ten or more. [6], End-play checks were conducted during a periodic comprehensive airframe overhaul process called a "Ccheck". Therefore the interval between jackscrew inspections was effectively increased from 26 to 30 months without the FAA spending a single minute looking into whether or not this was appropriate. Many of Alaskas maintenance workers received on the job training only without any formal curriculum. The problem, again, was a lack of redundancy: if the threads on the nut failed, there was no other structure that could absorb the load, and the catastrophic failure of the trim system leading to the loss of the airplane was inevitable. You got it? The report noted that the crash could have been avoided if they had immediately returned to Puerto Vallarta when they encountered the jammed stabilizer. Eventually, this gap increases as the acme nut threads wear. Lets do that. Thompson attempted to move the stabilizer trim using either the electrical switches, the trim handles, or both, in an effort to clear the jam. [6]:1011 First Officer William "Bill" Tansky, 57, had accumulated 8,140 total flight hours, including about 8,060 hours as first officer in the MD-80. Weve run just about everything. Note: this accident was previously featured in episode 2 of the plane crash series on September 16th, 2017, prior to the series arrival on Medium. Robo ^Tir in Autos & Vehicles. While the CVR captured only the last half-hour of the flight, the flight data recorder (FDR) had hundreds of parameters from the entire flight. Therefore, the NTSB concluded that "more than just the last lubrication was missed or inadequately performed". Then in 1999 Alaska Airlines retaliated against John Liotine, putting him on indefinite leave from his job and circulating false rumors about him; the airline sought to portray him in the media as a disgruntled employee who wanted to get back at supervisors who passed him over for promotion. Both the horizontal stabilizer trim system jackscrew (also referred to as "acme screw") and the corresponding acme nut, through which the jackscrew turns, were found. [6], A periodic maintenance inspection called an "end-play check" was used to monitor wear on the jackscrew assembly. In interviews with the Alaska Airlines mechanic at SFO, who last performed the lubrication, the task was shown to take about one hour, whereas the aircraft manufacturer estimated the task should take four hours. It went down, it went to full nose down.. The jackscrew was constructed from case-hardened steel and is 22in (56cm) long and 1.5in (3.8cm) in diameter. It aggressively took action to improve itself by hiring a new vice president (VP) of safety who reported directly to the CEO, filling executive vacancies in safety and maintenance, creating a large safety office, hiring 130 new mechanics, revising its general maintenance manual and reviewing every C-check aircraft in the fleet to ensure that all work was properly performed. The tragedy of 261 forced us to change, he said. The acme nut was constructed from a softer copper alloy containing aluminum, nickel, and bronze. Ah, here we go, said Captain Thompson, uttering the last words captured on the cockpit voice recorder. Flight 261 was on its way from Puerto Vallarta to San Francisco when a mechanical failure caused it to plunge into the ocean, killing all 88 people on board. [36] While the financial terms of settlements had not been officially disclosed, The Seattle Times reported the total amount to be in excess of US$300 million, covered entirely by insurance, which at the time was among the largest payouts in modern aviation history. Meanwhile in the cockpit, the pilots tried to figure out what had happened. Liotine began working with federal investigators by secretly audio recording his supervisors. That was the last time anyone ever measured the wear on the jackscrew nut on N963AS. Were pretty busy up here working this situation. Those who lost loved ones when Alaska Airlines Flight 261 plunged into the Pacific Ocean off California have learned some hard, bitter truths in the 10 years since the crash. The effect was immediate and catastrophic, as his inputs ripped out whatever threads remained on the jackscrew nut. Alaska Airlines Flight 261 was an Alaska Airlines flight of a McDonnell Douglas MD-83 plane that crashed into the Pacific Ocean on January 31, 2000, roughly 2.7 miles (4.3km; 2.3nmi) north of Anacapa Island, California, following a catastrophic loss of pitch control, killing all 88 on board: two pilots, three cabin crew members, and 83 passengers. As far as the pilots were concerned, the electric motors had probably seized and they could fly on to San Francisco without trimming the stabilizer. Still flying inverted, the plane leveled further, to nine degrees nose down. Less than one second later, Alaska Airlines flight 261 slammed into the Pacific Ocean, obliterating the aircraft and instantly killing all 88 people on board. Alaska Airlines Flight 261 was an international passenger flight from Puerto Vallarta to a stopover in San Francisco International Airport, to its destination in Seattle-Tacoma International Airport which suffered a serious mechanical failure on January 31, 2000, while flying over the Pacific Ocean, 4.3 km north of Anacapa Island in California.The two pilots, three flight attendants and the . The grease was green in color and differed from Boeings specified grease, Mobilegrease 28, which was red. In theory this was adequate, but only if the grease was applied correctly every time. Meanwhile, N963AS continued to fly, and maintenance workers continued to grease the jackscrew every eight months. By torqueing the screw up and down without turning it, and measuring the amount of play in the system, it was possible to roughly determine the depth of the wear on the nut threads, which the manufacturers guidelines stated must be less than one millimeter. The McDonnell Douglas MD-8-61 was made in Long Beach and was then . SEATTLE On January 31, 2000, Alaska Airlines Flight 261 plunged into the Pacific Ocean off the coast of . Almost all of these recommendations were implemented. The whole episode must have left him a bitter man although unlike most whistleblowers, he did manage to restart his career in the industry. All passengers were identified using fingerprints, dental records, tattoos, personal items, and anthropological examination. The crew scrambled to react to the massive upset. With the stabilizer angled 3.1 degrees toward nose down, more than the design maximum of 2.5 degrees, flight 261 immediately entered a high-speed dive, hurtling downward at more than 6,000 feet per minute. More than half of these were directly related to jackscrew lubrication and end-play measurement. We noticed a lot of differences. But in the end, Alaska all but got away with it. [38] Many residents of Seattle had been deeply affected by the disaster. Okay, well, your discretion, said maintenance. Talk about lessons learned! Like its earlier DC-9 variant, longitudinal trim control for the MD-80 is provided by the 40-foot-wide horizontal stabilizer mounted atop a vertical fin in a T-tail configuration. On December 22, 1998, federal authorities raided an Alaska Airlines property and seized maintenance records. But in the end he was forced to accept a mere $500,000 settlement, far less than the $20 million he had sought, and only then on the condition that he resign from his job. Lives would have been saved if they had. It was no wonder, given these findings, why Alaska Airlines mechanics didnt know how to grease the jackscrew, and why nobody held them accountable for not doing so properly. For several months he surreptitiously recorded his bosses violating safety rules and handed the tapes over to FAA investigators. Finally, at 16:19 and 21 seconds, the stop gave way with a faint thump. Some did still less, failing even to ensure that grease totally filled the inside of the nut. Yeah, no, said Thompson. El Camino HS academic decathlon team wins national championship, May Day rallies underway in downtown LA to fight for worker rights, Suspect in stolen vehicle causes massive pileup in San Bernardino. The Gulf of California stretched out below them, bright and blue. The only layer of protection against a catastrophe was therefore the assumption that poorly trained, low-paid maintenance workers would apply enough grease. But neither of the applicable checklists said anything about landing at the nearest available airport, and by the time they finished the checklists and leveled off at 31,000 feet, minimal effort was required to keep the plane flying level. However, this premise was based on the assumption that one of the threads might separate from the nut due to metal fatigue or improper workmanship, and did not consider the possibility of abnormal wear simultaneously compromising the strength of both threads. [31] The sundial casts a shadow on a memorial plaque at 16:22 each January 31. At 16:09, he said, Im gonna click it off. When greased regularly, the nut on the MD-80 series is designed to last for 30,000 flight hours before requiring replacement long enough that most planes will see only two or three different jackscrew nuts during their entire time in service. After the crash, we discovered that the work order had not been acted upon because a second inspection team had rechecked five times and found endplay to be within limits at .033.. Then, additional grease was to be applied to the entire length of the screw, filling all the threads. "[21][22] The aircraft was destroyed by the impact forces, and all occupants on board were killed by blunt-force impact trauma. gakirah barnes death video; Financial Planning. I think its at the stop, full stop, said Thompson. The airline was convinced that Aeroshell 33 was causing corrosion. [26], The investigation then proceeded to examine why scheduled maintenance had failed to adequately lubricate the jackscrew assembly. The stabilizer is attached to a giant threaded screw, called the jackscrew, which feeds through a nut attached to the aircraft structure inside the tail. But the measurements were imprecise and repeated tests often produced different results allowing a certain amount of ambiguity as to whether the value was over or under the limit. Four minutes later, a warning light illuminated to inform the crew that the autopilot was unable to move the stabilizer.