The Crash that very eventually made air travel safer for millions


The National Transportation Safety Board determined that a jammed valve in the rudder control system caused the crash of USAir Flight 427.
The crash a decade ago of USAir Flight 427 killed 132 passengers and crew, victimized countless others and made air travel safer for millions of future passengers.

"I can't think of one accident that had more impact on the NTSB, on the aviation industry, and more importantly, on how families of all disasters are treated worldwide than the Pittsburgh accident," said Jim Hall, chairman of the National Transportation Safety Board during the Flight 427 investigation.

The NTSB gained credibility by solving the mysterious crash and successfully demanding a billion-dollar fix to prevent morecrashes. Since then, the federal safety agency has commanded more safety improvements in other types of planes.

 "Nothing can replace those who were lost in that accident," said Hall, now a transportation safety and security consultant in Washington, D.C. "But hopefully, their loved ones can look back at that tragedy and know, as a result of that event, possibly hundreds or thousands of lives may have been saved over the lifetime of that airplane, which is still the world's most popular aircraft."

Flight 427's greatest contribution may be the revelation of a flaw in the rudder mechanism of the Boeing 737. In the end, investigators discovered that a valve in the rudder control unit -- about the size of a soup can -- sometimes jammed.

 "There's more than a million people who ride in 737s daily," said Capt. John Cox, a US Airways pilot who chairs the Air Line Pilots Association's air-safety group. "All of those people are in a safer aircraft."

A billion-dollar fix

Flight 427, USAir's fifth crash in five years, strongly resembled the 1991 crash of United Flight 585 in Colorado Springs, also a Boeing 737.

Initially, some blamed wind patterns for both crashes and even pilot error for Flight 427.

The NTSB found a problem in the design of the Boeing 737's rudder control system. Specifically, a valve called a servo valve could jam and swing the hinged piece of the tail, called a rudder, all the way to one side.

In 1999, the NTSB made its theory official: The servo valve jam caused Flight 427 to roll left and spiral to the ground in about 28 seconds on approach to Pittsburgh International Airport.

"It was kind of a tough call to say the aircraft is really unsafe. But it became obvious that this needed a redesign," said Tom Haueter, the NTSB's lead investigator. "It caused a complete rudder redesign on the 737 series of aircraft -- it was almost unprecedented."

The Federal Aviation Administration acted on the NTSB's recommendations.

"Since the USAir 427 accident, the FAA has worked with Boeing, the NTSB and industry to make the 737 rudder system safer," said FAA spokesman Les Dorr.

The FAA ordered training for pilots on how to handle a rudder problem, modification of existing planes so rudders could not fail and installation of new rudder systems by 2008. The new systems essentially add a backup rudder control.

Flight 427 shed light on other mysterious incidents involving Boeing 737s.
It allowed the NTSB to conclude the Flight 585 crash also occurred because of the valve flaw. And the NTSB ruled a

valve jam caused an incident with Eastwind Airlines Flight 517 in 1996 near Richmond, Va. It's suspected in several other incidents.

The ruling irked those in the industry opposing the flawed rudder explanation. For years, Boeing argued Flight 427 crashed because its pilot, Capt. Pete Germano, did not properly handle a wind disruption created by another jet.

Under pressure, Boeing finally implemented a billion-dollar change to the 737. New planes were built with what amounts to two rudder control units. If one accidentally jammed, the other could take over. Planes already flying were modified to prevent jams.

"At that time, it was the longest NTSB investigation," Hall said. "It started out with Boeing essentially denying for three years that a mechanical malfunction on the world's most popular jetliner could occur to what essentially was an admission by Boeing and, more importantly, a billion-dollar correction of that flaw."

Boeing would not comment for this story.

Leading the charge

Other troubling airliner crashes followed Flight 427 in the 1990s. Hall and the NTSB pursued those with the same vigor as Flight 427 and called for more safety changes on other types of planes. Solving the Flight 427 mystery gave the NTSB respect and teeth to enact change.

"To me, that was the accident that really formed me as a chairman of the NTSB and, I think, in many ways, transformed the NTSB into probably a more effective safety advocate," said Hall, who remained on the NTSB board for nearly eight years.

"Pittsburgh was the first major aviation disaster I handled as a chairman," Hall said. "I think the experiences out of that disaster and that investigation provided a blueprint for me in terms of how I wanted to hopefully impact the profile of the NTSB and approach disasters."

"In some cases, I was confrontational. That was what was required to change the culture of both the FAA and the airline industry in regard to safety. I think you can look now at the safety record of the industry and I think you would say those accidents in the 1990s really changed the safety culture of the aviation industry."

The NTSB's success in gaining mandated safety changes through those years came about in part because it was able to prove what caused Flight 427 to crash.

"It really validated the NTSB process because it was a very difficult accident to solve," said Cox, of the pilots association.

Help for families

The crash of Flight 427 also changed the way airlines and governments deal with the families of those killed.

Flight 427 families were herded into an airport lounge at Pittsburgh International. USAir employees told them there was an accident with fatalities. Then, they left. Six hours elapsed before families learned the truth.

Through the night, nobody told the relatives who or how many died. USAir denied health counselors access to the relatives and friends. Later, distraught people were allowed to drive home from the airport. Distressed airline employees were not permitted to seek counseling.

"As the anniversary of the 427 tragedy approaches, our thoughts are with the families of the passengers and crew," said US Airways spokesman David Castelveter. "Out of respect to their memory, we are going to limit our public comments to extending our sympathy and offering our support to the efforts of remembrance and reflection."

The airline's handling of the families was so problematic that it led President Bill Clinton to issue an executive order in 1996 and Congress to pass the Disaster Family Assistance Act later that year.

The law charged the NTSB with helping families of crash victims by becoming the central point of contact from the moment the crash happens until the investigation is complete. The NTSB brings in counselors and even helps arrange a memorial service.

The Flight 427 victims' families, most from Pittsburgh, formed a nonprofit group -- the National Air Disaster Alliance/Foundation -- that continues to help other victims of air crashes and lobbies for safety changes.

The group has helped victims from more than 100 aviation crashes. It is a member of the FAA's rule-making committee and has played a part in making significant safety changes, including putting smoke detectors in cargo holds and redesigning fuel tanks.

"With Flight 427, there were a lot of professional people from Pittsburgh that left behind so many widows. They bonded very quickly and found each other very quickly," said Gail Dunham, the group's director. "It was the USAir 427 family members who met and founded the group in Pittsburgh in 1995. That's one of the good things that's come out of it. We've accomplished many things."
 

from this link the Report History of USAir 427          link ONE link TWO
A Family Remembers

By PETER H. MILLIKEN

VINDICATOR STAFF WRITER

YOUNGSTOWN Ten years later, the crash of USAir Flight 427 still evokes painful memories for the Ricchiuti and Rubino families, who lost loved ones in the accident.

But they are grateful that the memories of Anthony Rich and his wife, Paula Rubino Rich, who died in the crash, live on at the Rich Center for Autism at Youngstown State University.

Coming from Chicago, USAir Flight 427 crashed in Hopewell, Pa., shortly after 7 p.m. Sept. 8, 1994, just seven miles from a landing at Pittsburgh International Airport. All 127 passengers and five crew members were killed.

'This void'

"It never goes away. There's always this void in your life. You always have this lump in your gut that just doesn't disappear," said Phyllis Ricchiuti of Poland, mother of Anthony Rich.

"The center has brought us some satisfaction that we have turned the awful thing that happened to us into something positive for the people of our community," she said of the autism center, which the two families helped to establish in 1995.

 
"You don't cry every day like you did initially, but you still remember them, and you still think about them every day," said Dr. Robert Ricchiuti, Anthony's father.

"We have no ill feelings against the airlines. Our son was a pilot, and he died doing what he wanted to do," Phyllis Ricchiuti said. When she expressed worry about his safety in the air, Anthony told her, "Just know, if I ever get killed in an airplane, I died happy," she recalled.

The Riches went back to their ancestral name, Ricchiuti, because Anthony and Paula had discussed making this change. "We thought, if the kids wanted to do it, maybe we should," Phyllis Ricchiuti explained.

Had visited Italy

Paula and Anthony Rich, of North Yarmouth, Maine, formerly of Poland, had been visiting the Rubino family's village in Italy with Paula's parents, Fernando and Rose Rubino of Poland, when the two couples got separated for the flight home. The Rubinos flew home on TWA, but the Riches had to take another flight because, for unknown reasons, TWA wouldn't accept their tickets.

"It gets a little softer, but it doesn't ever go away, especially this time of year," said Fernando Rubino, a general contractor, who donated his time, along with others, and used donated materials to make the Rich Center wheelchair-accessible 18 months ago.

"We miss them so much. We can only imagine how many children they might have had and what they would have been like," Rose Rubino said.

"I have meltdowns all of August and September because it's my birthday. It's Paula's birthday. It's their wedding anniversary and the anniversary of their death," said Rose Rubino. The Riches were married Sept. 5, 1992, and Paula was four months pregnant with their first child when she died.

Rose Rubino also said the birthday of her daughter, Jacqueline Marchionda of Poland, also falls at the same time of year.

Reason for autism center

The autism center was established because Anthony and Paula Rich were godparents to Marchionda's son, Christopher, who had been diagnosed with autism just before the crash, Phyllis Ricchiuti explained. Christopher, now 13, attends the Rich Center's summer program.

"They would be so proud of what we have done in their names to help families in our community," Phyllis Ricchiuti said of her son and daughter-in-law.

Besides Phyllis Ricchiuti, Rose Rubino and Jacqueline Marchionda, the other co-founders of the Rich Center are Geri Kosar and her daughter, Beth Kosar, both of Boardman, and all are still on the board of directors. Beth Kosar's sons, Brian and Josh, both autistic, attend the center's summer program.

Cause of crash

As for the crash and its cause, Marchionda and the Rubinos attended the hearings of the National Transportation Safety Board, which were part of the longest aircraft accident investigation in the board's history. The investigation concluded in March 1999, with the board determining that a rudder reversal likely caused the crash.

"We haven't had any other accidents like that since then. It was such a freak thing. It was so freaky because it was absolutely the most gorgeous day not a cloud in the sky. The temperature was perfect. They could see the runway in front of them," Phyllis Ricchiuti said.

"I feel that they investigated it very well," Dr. Ricchiuti said. In previous rudder reversal incidents, the planes were at higher altitudes, which allowed an opportunity for recovery, he observed. "With our kids, unfortunately, they were making an approach, and they were only a mile or so off the ground, and there was no way they could recover in time," he added.

Rose Rubino noted that, since the accident, recovery from rudder reversals has been included in pilot training.

"Ten years seems like yesterday. Nevertheless, it does amaze me that people still, almost on a daily basis, express their sympathy for our loss. We feel blessed by that. We feel especially blessed with this center here. It does give us a lot of consolation," Dr. Ricchiuti said at the Rich Center, where he and his wife and the Rubinos were interviewed.

The Ricchiuti and Rubino families have remained close to each other over the past decade. "We get along so well, and I hope we continue that way the rest of our lives. We have to stick together and go on," Fernando Rubino concluded.

from this link

Crash's legacy is painful, but lessons were learned

 
The Story (Series): in 6 parts
Print Story Discuss this story

Third parties work with families of air disaster victims.

By PETER H. MILLIKEN

VINDICATOR STAFF WRITER

The widow of a Greenville, Pa., area native killed in the crash of USAir Flight 427 still doesn't think Boeing 737s are safe airplanes.

"I wish there were no 737s flying because I'm not sure that it's not going to happen again," said Alice Grasso of Monroeville, Pa. She was referring to the rudder reversal that the National Transportation Safety Board said was the likely cause of the crash.

She is the widow of Leonard C. Grasso, 41, who died when USAir Flight 427, a Boeing 737-300, crashed Sept. 8, 1994, killing all 132 people aboard.

Leonard C. Grasso was formerly of West Salem Township, just outside Greenville, and was a graduate of Reynolds Area High School. He was senior manager of asset management for the Bessemer and Lake Erie Railroad, with headquarters in Monroeville.

"The probable cause is what they said caused it, but it really isn't a definite answer," Alice Grasso said. She noted that changes have been made in pilot training, and a rudder limiter has been placed on 737s since the crash, but she added that she doesn't fly in 737s.

Conclusion of investigation

Concluding what had been the longest aviation accident investigation in its history, the NTSB announced March 24, 1999, that the crash of Flight 427 was likely because of loss of control of the plane because of the movement of the rudder to its maximum limit. The NTSB said the rudder likely went in the direction opposite to what the pilots commanded because its power control unit jammed.

The board said such reversals are extremely rare and noted that the 737 had logged 92 million flight hours since its introduction in 1969, "and in that time carried almost the equivalent of the entire population of the world."

"The NTSB was really good. They listened to us," Grasso said, adding that the board arranged special seating for victims' families at hearings on the crash and held some of the hearings in Pittsburgh. She said it was the first time such hearings were held outside the Washington, D.C., area.

Disaster plan

Two years after the crash, Congress passed and President Clinton signed a bill titled the Federal Family Assistance Plan for Aviation Disasters. It designated the American Red Cross or the Salvation Army as third parties to give information and assistance to families of victims after a crash so the families would no longer have to deal with the airline whose plane crashed.

The 427 Air Disaster Support League, consisting of families and friends of victims, worked with families of victims and survivors of other disasters to form the National Air Disaster Alliance based in Washington, D.C., to lobby for passage of that bill, Grasso said.

Grasso said her daughters, who were 4 and 7 years old at the time of the Flight 427 crash, are in high school. Today is her older daughter's 17th birthday. "It's very tough for her," she said of the proximity of her birthday with the anniversary of her father's death.

The sister of another crash victim said the passage of time reduces, but does not eliminate, the pain of bereavement.

"As time goes on, it does get a little easier, yet you don't forget. It still hurts," said Mary Kulnis of New Castle, Pa, sister of Robert E. Leonhardt of Neshannock, who died in his mid-40s in the Flight 427 crash.

Leonhardt, whose widow, Roseann, lives in Neshannock, worked for Rockwell International and was returning home from a business trip to Chicago on Flight 427.

Painful memories

"We think about him constantly," Kulnis said. She added that her memory of the crash comes back anytime planes or plane accidents are mentioned on TV or in conversation. "It brings it all back to you. It's just like it was yesterday, almost," she said.

Kulnis said she initially suspected a rudder problem had caused the crash, but she holds no grudge against the airlines. "Things happen in life, and you can't be angry about it," she concluded.

from this link

to Safety Menu