Still unknown: Who was responsible for failed repair?

By Timothy R. Gaffney tgaffney@daytondailynews.com

WASHINGTON | Failure to secure a bolt caused the fatal crash of a Dayton-based Emery Worldwide Airlines cargo jet more than three years ago, a federal safety panel ruled Tuesday.

The National Transportation Safety Board's investigative team had focused on the bolt and related maintenance issues through most of its inquiry into the Feb. 16, 2000, crash near Sacramento, Calif.

But precisely when the maintenance failure happened and who was responsible — Emery's own mechanics or a contractor — remains a mystery.

The DC-8 airliner crashed on Feb. 16, 2000, in Rancho Cordova, Calif., two minutes after takeoff on a flight bound for its Dayton hub. All three crewmembers died — Capt. Kevin Stables, 43, of Berlin, N.Y.; First Officer George Land, 35, of Placerville, Calif.; and Second Officer Russell Hicks, 38, of Sparks, Nev.

The pilots fought to control the plane from the moment it took off until it plunged into a closed auto-auction yard, carving a fiery swath where hundreds of people had stood hours earlier.

In Tuesday's meeting, the NTSB's five members unanimously adopted their staff's findings, including one that a bolt

connecting part of the plane's elevator-control system worked its way out, causing the elevator to jam in a way that forced the plane into an extreme nose-up position as it took off.

Investigators said a maintenance contractor, Tennessee Technical Services of Smyrna, Tenn., had replaced the plane's elevators in November 1999, about three months before the crash. But they also learned Emery maintenance personnel had worked on the plane's elevator at least twice before the crash.

Investigators found Emery's maintenance documents too fuzzy to determine just who did what — or even what was supposed to have been done.

"There was insufficient evidence for (the NTSB) staff to determine exactly when or how the bolt was improperly secured," said Frank Hilldrup, the board's staff investigator in charge of the inquiry.

"This event was a tragedy," NTSB Chairwoman Ellen G. Engleman said. "It illustrates the interdependence and critical roles and responsibilities of each member of the aviation safety chain. Safety requires 100 percent performance by everyone."

The ruling concluded the board's investigation of an accident that came amidst Emery pilot complaints about safety problems with the airline and raised questions about oversight of airline maintenance practices, both by government regulators and the airlines themselves.

Besides ruling on the cause, the board made 15 safety recommendations to the Federal Aviation Administration, including provisions for revised maintenance procedures, improved training for flight crews, the redesign of DC-8 elevator-control tab installations, and replacement of DC-8 aluminum elevator-geared tab crank arms.

The NTSB is an independent panel that recommends safety improvements but has no enforcement powers.

Emery grounded its airline fleet on Aug. 13, 2001, when the FAA threatened to revoke its license for 100 alleged safety violations unearthed in a series of inspections dating from January 2000, a month before the crash.

Emery's parent company, CNF Inc. of Palo Alto, Calif., later disbanded the airline in a reorganization. The FAA revoked the airline's operating certificate in December 2002.

The NTSB's findings and recommendations mainly focused on issues with the design of the control linkage involved in the crash and on related safety procedures.

But John Goglia, the board member who followed the crash investigation most closely, said afterward he thinks the crash involved safety issues that go beyond problems specific to the aging DC-8s or the defunct Emery airline.

"It's clear that many of the elements that led to the crash of ValuJet in the Everglades were present in this accident as well," Goglia said, referring to the 1996 airline crash that killed 110 people.

Investigations of the ValuJet crash revealed a trend among discount passenger airliners to contract out much of their work, including maintenance, with little oversight from the Federal Aviation Administration.

Emery also contracted out much of the maintenance work for its airplanes, and Goglia, a certified aircraft mechanic, was harshly critical of Emery's maintenance management during a hearing in May 2002.

In June, a Department of Transportation Inspector General's report also sharply criticized the FAA for lax oversight of aircraft maintenance companies.

"Air carriers have increasingly gravitated (from company-owned facilities) to repair stations for aircraft maintenance, yet FAA has made no similar shift in its oversight of these facilities," it said.

At Tuesday's meeting, Goglia added two recommendations to improve maintenance practices throughout the airline industry. One would require airlines to give mechanics explicit directions on how to do specific maintenance tasks. The other would require airlines to make sure repair manuals were accompanied by up-to-date installation drawings.

Goglia was sharply critical of Emery on both counts, but at Tuesday's hearing he also pointed out the board had urged the FAA to require more explicit maintenance instructions after a 1996 accident.

Goglia said the board later ruled the FAA's response to the recommendation "acceptable" when the agency issued guidance to its primary maintenance inspectors.

"Maybe we were premature....  At least the message didn't get down to the (FAA inspector) on Emery," Goglia said.

Family members of the victims were relieved that the board officially cleared their names, said Fred Chesbro, Stables' brother-in-law and a military pilot based in Hawaii.

But Chesbro said he was surprised at the board's lack of recommendations on oversight issues.

"The probable cause finding seemed (to have) a narrow technical focus. I don't think it means the (oversight) issues are any less present," he said.

CNF Spokeswoman Nancy Colvert said the board's action closes the case on the accident, but she noted several civil lawsuits are pending.