By Steve Miletich
Seattle Times staff reporter
Federal safety investigators have concluded that risky maintenance
practices permitted by the Federal Aviation Administration, combined
with a design flaw in a key airplane mechanism, led to the fatal crash
of Alaska Airlines Flight 261 in January 2000.
In a draft report nearing its final stages, the staff of the
National Transportation Safety Board says "insufficient lubrication"
led to the failure of the jet's jackscrew mechanism, a key component
in the plane's tail. It portrays Alaska as an airline that operated on
a thin margin of error, with serious flaws in its maintenance
But the report also faults the design of the plane, an MD-80 built
by McDonnell Douglas before its 1997 merger with Boeing. That
represents a setback for Boeing, which has argued that the crash
wouldn't have occurred if the jackscrew mechanism had been properly
Flight 261: Key recommendations
A draft report by the staff of the National Transportation Safety
Design changes to Boeing MD-80 series and 717 jets to prevent the
kind of catastrophic failure that led to the Flight 261 crash.
More direct Federal Aviation Administration oversight of airlines'
maintenance practices; less reliance on airlines to govern themselves.
Another top-to-bottom inspection of Alaska Airlines' maintenance
operations to ensure that changes promised in the wake of Flight 261
have been carried out.
If upheld by the safety board and the FAA, the finding could lead
to an order for modifications to MD-80-series planes as well as the
717, a cousin of the MD-80 that is still built by Boeing at a former
McDonnell-Douglas plant in California. More than 1,400 jets could be
The report will be submitted to the safety board's four appointed
members before a public hearing tentatively set for Dec. 10 in
Washington, D.C. Key portions of the draft were read to The Seattle
Times by an official close to the investigation.
Alaska, Boeing and the FAA declined to comment pending the release
of the findings.
Ted Lopatkiewicz, chief spokesman for the safety board, said
yesterday that board members had not seen the draft report and could
make "substantial revisions" in it.
Flight 261 crashed Jan. 31, 2000, off Southern California, killing
all 88 passengers and crewmembers as the plane was en route from
Puerto Vallarta, Mexico, to San Francisco and Seattle.
The report, as expected, concludes that the probable cause of the
crash was failure of the jackscrew mechanism, which sent the MD-83
into a dive into the Pacific.
The jackscrew is a 2-foot-long, 1-1/2-inch-diameter threaded shaft
that moves up and down, raising and lowering the leading edge of the
stabilizer, the winglike structure on the tail that controls the
plane's angle of flight.
The report says a lack of grease in critical areas of the jackscrew
assembly caused excessive wear, stripping threads from the mechanism's
stationary gimbal nut. The jackscrew moved beyond its limits, causing
the stabilizer to fail.
While the report doesn't pinpoint the reason for the lack of
grease, it states that Alaska, with the FAA's approval, reduced the
frequency with which it lubricated the mechanism, increasing the
likelihood of excessive wear.
Alaska, also with the FAA's assent, increased the inspection time
to detect wear on the mechanism, the report says.
Since the crash, Alaska has completely revamped its procedures
under pressure from the FAA. The FAA, itself under scrutiny, has
bolstered its oversight of the carrier.
For Boeing, the most significant part of the report is its
conclusion that the MD-80's design is faulty because it doesn't
account for the "catastrophic effects" of complete thread loss on the
Without a required backup system, the pilots had no way to regain
control of the plane when the jackscrew mechanism failed.
The MD-80 series was manufactured beginning in 1980 by McDonnell
Douglas and discontinued by Boeing in 2000. It is based on the Douglas
DC-9, which dates to the mid-1960s.
In addition to the findings regarding the cause of the crash, the
safety-board report recommends that the FAA:
* Take more control over changes to maintenance intervals, instead
of leaving the decision in the hands of airlines' internal-review
* Order airlines to follow stricter protocols for lubricating
aircraft components, including requiring that airline safety
inspectors personally sign task cards to assure that lubrications have
been done properly. The board's staff, after discussion, decided not
to require that jackscrews be automatically replaced at regular
intervals instead of when they wear out. But it did recommend the FAA
establish training requirements specifically for mechanics who inspect
and overhaul jackscrew mechanisms.
* Require Boeing to modify MD-80-series planes still in use, as
well as 717s, to add backup systems. Boeing has indicated to the board
that it could make two or three such changes. About 1,190 MD-80s, 115
MD-90s and 106 717s could be affected. The cost has not been
* Issue a bulletin to pilots instructing them not to try to fix
jackscrew problems in flight, but to land at the nearest airport. The
two pilots aboard Flight 261 fought problems for at least 30 minutes
before the crash.
* Conduct another major inspection of Alaska's maintenance
operations, as it did in April 2000, to make sure the carrier has
fully adopted changes stemming from that review.
Some board investigators still have concerns about the airline's
practices, a senior official said.
The April 2000 inspection prompted the FAA to threaten to shut down
Alaska's major-repair facilities. The airline averted the action by
making sweeping changes in its maintenance program, including the
hiring of hundreds of mechanics.
The new inspection should go beyond a review of paperwork and
include visual inspections of Alaska's procedures, the report says.
The jackscrew that failed during Flight 261 had been found to be at
its maximum allowable wear limit during a September 1997 test, but
flew for 25 months without another inspection before the crash.
Even though a senior Alaska mechanic called for replacement of the
component after the 1997 test, other mechanics re-checked it, found it
to be well within limits and decided not to replace it as the plane
was nearing its release date.
Safety-board investigators have found that some Alaska maintenance
logs that were supposed to be kept at the time of those tests are
missing, said the official close to the investigation.
The report's finding regarding insufficient lubrication followed a
fierce internal debate among the safety board's staff about whether to
allege the jackscrew assembly had not been greased at all, the
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But because task cards were filled out stating lubrications had
occurred, there was no way to prove they weren't done, the official
said. Alaska has asserted that a jammed fitting possibly obscured a
lack of grease.
Just in the past two months, Alaska sharply increased how often it
lubricates all components in its MD-80-series jetliners when problems
The safety board's findings will be closely reviewed by lawyers
representing dozens of families with wrongful-death suits against
Alaska and Boeing, as well as attorneys defending the companies.
A federal trial that could cost the companies millions of dollars
in damages is set to begin in April in San Francisco. Boeing is liable
for potentially huge punitive damages; Alaska is not because of an
international aviation treaty protecting carriers.
"The findings of the NTSB have been long-awaited by the families,"
said Jamie Lebovitz, a Cleveland attorney representing 18 families,
"and will certainly be of value in the civil proceedings."
Lebovitz said the plaintiffs have gathered evidence showing
McDonnell Douglas knew years ago that jackscrew mechanisms were
vulnerable to wear, but never instructed pilots how to deal with a
On Flight 261, the "pilots were turned into test pilots," he said.