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The actual protocol at Alaska Airlines was to inspect the jackscrew for wear at every second C-check, a comprehensive multi-day inspection that every airplane undergoes approximately once a year. On the basis of these measurements, the shift supervisors overruled Liotines earlier work order and cleared the plane to fly. They descended to a lower altitude and started to configure the aircraft for landing at LAX. The maintenance technician, having received all the information he could get, said, Okay, thank you sir, see you there., Meanwhile, the conversation had apparently encouraged Captain Thompson to try moving the stabilizer again. 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. By now the plane had leveled out at about 23,500 feet, after plunging 7,500 feet in 80 seconds. For the next few minutes, they calculated landing weights and center of gravity and other values while controllers in Los Angeles prepared to accommodate them. We also noted that accessing the area for the lubrication was unwieldy, especially on a tail stand at night (images 10 & 11). Alaska has not had a fatal crash since the overhaul, nor has there been another major loss of a US airliner due to any kind of mechanical failure. In hindsight, the crew should have turned around and immediately landed back in Puerto Vallarta. PLANE CRASH, Alaska Airlines Flight 261, Pacific OceanOther Videos:https://www.youtube.com/playlist?list=PLqoJItjw7txOS5AjsLzo8x95z9cvoMFxeAlaska Airlines Fl. As flight 261 climbed through 23,400 feet at approximately 13:49 that day, the badly worn threads started to tear away from the nut, wrapping themselves around the jackscrew and causing the stabilizer to jam. On every level, it was a tragedy that did not need to happen and to this day, it serves as a grim example of the depths to which an airline may fall when oversight becomes too thinly stretched. The green grease did appear to be more wet to me. It got worse, okay. Violent vibrations shook the airplane. Upon crossing the Mexican border while tracking north off the coast of San Diego, the CVR began to pick up the crew conversations regarding the jammed stabilizer and initial dive. Alaska Airlines now flies from Puerto VallartaSeattle/Tacoma nonstop with Flight 127 and Puerto VallartaSan Francisco nonstop with Flight 1273. The Gulf of California stretched out below them, bright and blue. Neither the flight crew nor company maintenance could determine the cause of the jam. Some applied grease only through the single zirk fitting of the acme nut we learned that numerous pumps of the grease gun did not provide enough grease on the jackscrew after it was run up and down. However, the pilots were clearly under pressure to continue on to San Francisco, and maintenance technicians and dispatchers on the ground did not appreciate the direness of the situation. Yeah, no, said Thompson. I think the stab trim thing is broke, said Thompson. The leading edge of the stabilizer can be raised or lowered as it pivots about a rear hinge point. It began life as a regional airline in Alaska, and by the time deregulation arrived in the late 1970s, it only had one destination in the lower 48 states. Flight 261 immediately plunged into a near-vertical dive, hurtling downward toward the Pacific Ocean. [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. But after Liotine left for the night, the next shift and the shift supervisors decided to run the test again before taking his measurement at face value. Thompson continued to think about ways to unjam the stabilizer. At 15:55, the dispatcher returned with wind speeds, wind directions, and runway conditions at San Francisco and Los Angeles. 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. [6] The accident showed that certain wear mechanisms could affect both sets of threads and that the wear might not be detected. The plane was scheduled to land at San Francisco International Airport (SFO). They've. 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. The plane dropped from about 31,500ft (9,600m) to between 23,000 and 24,000ft (7,000 and 7,300m) in around 80 seconds. In some accidents, relatives of those who died can take some small comfort in the possibility that their loved ones never knew what hit them. Were going to LAX, Thompson told the dispatcher. [23] In addition, both engines, as well as the flight data recorder (FDR) and CVR were retrieved. Ameet Prasad lost his younger brother . Thompson along with Captain Bill Tansky had just pulled out of an uncommanded dive from 31,000 feet to 23,000 feet. Keep us advised.. The night shift subsequently performed the test five more times and measured a wear depth of approximately 0.84mm on each attempt. 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. On board flight 261, Captain Thompson vented to First Officer Tansky: Drives me nuts, he said. It added dozens of new routes, expanded to a large number of new cities, and even added services to Mexico in order to offset the seasonal nature of its flights to Alaska. [37] Candy Hatcher of the Seattle Post-Intelligencer wrote: "Many lost faith in Alaska Airlines, a homegrown company that had taken pride in its safety record and billed itself as a family airline. If done correctly, the process took about four hours. Stepping on the rudder pedals while upside down was no easy task. From the best and brightest scientists, explorers, photographers, and filmmakers, Nat Geo is the world's premium destination for science, exploration, and adventure. Watching the death throes of flight 261, the SkyWest pilot told controllers, Yeah, hes inverted., Okay, said the controller, apprehension evident in his voice. The names of Morris Thompson and Ronald and Joyce Lake were used in schemes unrelated to them. [6], A special inspection conducted by the NTSB in April 2000 of Alaska Airlines uncovered widespread significant deficiencies that "the FAA should have uncovered earlier". This past January, to honor the victims of flight 261 on its 20th anniversary, hundreds of family members, friends and loved ones came together in Ventura around the Memorial Sundial constructed after the crash. The airline continued to assess its own safety culture and leadership through the years in what became an obsession to improve safety. At 16:07, flight 261 contacted Alaska Airlines Los Angeles maintenance facility on the radio. But the mechanism by which Alaska Airlines fell to such a dismal level of safety is not entirely gone. 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. The report noted that the crash could have been avoided if they had immediately returned to Puerto Vallarta when they encountered the jammed stabilizer. Its on the stop now, its on the stop, Thompson said. Whatever we did is no good, dont do that again, said Tansky. Alaska Airlines Flight 261 was a flight from Licenciado Gustavo Daz Ordaz International Airport in Puerto Vallarta, Jalisco, Mexico, to Seattle-Tacoma International Airport in Seattle, Washington, United States, with an intermediate stop at San Francisco International Airport in San Francisco, California. Uh, if you want to try it, thats ok with me, if not, thats fine. The whole episode must have left him a bitter man although unlike most whistleblowers, he did manage to restart his career in the industry. This and other evidence suggested to the NTSB that "the SFO mechanic who was responsible for lubricating the jackscrew assembly in September 1999 did not adequately perform the task". The subsequent investigation by the National Transportation Safety Board (NTSB) determined that inadequate maintenance led to excessive wear and eventual failure of a critical flight control system during flight. Meanwhile, N963AS continued to fly, and maintenance workers continued to grease the jackscrew every eight months. An Alaska Airlines pilot, involved in the investigation of the horrific crash of Alaska Flight 261, has listened to the cockpit voice recorder from the downed plane and he reported that for the . The basic design of the stabilizer is relatively simple. Mechanical stops attached to the jackscrew prevent the stabilizer from moving farther than 2.5 degrees upward or 12.5 degrees downward. [42], Two victims were falsely named in paternity suits as the fathers of children in Guatemala in an attempt to gain insurance and settlement money. Cockpit voice recorder (CVR) transcripts indicate that the dispatcher was concerned about the effect on the schedule ("flow"), should the flight divert. Captain Thompson was not happy with this reasoning. And hes just hit the water, said one pilot. Thus the fundamental principle of redundancy was violated. Since each lubrication or end-play check subsequently not conducted had represented an opportunity to adequately lubricate the jackscrew or detect excessive wear, the NTSB examined the justification of these extensions. A special inspection by the FAA after the accident found further evidence of a massively deficient safety culture at Alaska Airlines. [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. Indications of questionable maintenance were noted, including the fact that the airline was using a newer type of grease on the jackscrew called Aeroshell 33. The movement, or end play, between the gap of the acme nut and jackscrew threads is measured with a dial indicator and read in thousandths of an inch (see image 8). Yeah, we got it back under control here.. The controller granted the block altitude. [6], In 2001, the National Aeronautics and Space Administration (NASA) recognized the risk to its hardware (such as the Space Shuttle) attendant upon the use of similar jackscrews. We went to full nose down and Im afraid to try it again to see if we can get it to go in the other direction.. The NTSB examined why the last end-play check on the accident aircraft in September 1997 did not uncover excessive wear. The investigation found that Alaska Airlines had fabricated tools to be used in the end-play check that did not meet the manufacturer's requirements. [6], Alaska 261 informed air traffic control (ATC) of their control problems. The acme nut was constructed from a softer copper alloy containing aluminum, nickel, and bronze. Repeated attempts to overcome the jam with the primary and alternate trim systems were unsuccessful. With the jackscrew completely separated from the nut, aerodynamic forces acting on the stabilizer pushed it up beyond the normal full nose down position, halting only when the mechanical stop on the bottom of the jackscrew slammed into the nut. how to print presenter notes in canva alaska airlines flight 261 pilot drunk. 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 crew of a SkyWest airliner reported, "He's, uh, definitely out of control. The stabilizer on the MD-80 series rests on top of the tail, and like all airliners, it can move up and down to adjust the pitch angle at which the plane is stable. "[6]:9 Over the next minute, completely inverted and still diving at a -9 degree pitch, the crew struggled to roll the plane, with the captain calling to "push push pushpush the blue side up," "ok now lets kick rudderleft rudder left rudder", to which the copilot responded, "I can't reach it". The only layer of protection against a catastrophe was therefore the assumption that poorly trained, low-paid maintenance workers would apply enough grease. Saudi Arabian Airlines Flight 763/Kazakhstan Airlines Flight 1907 Crash Documentary - Sigh. [8][9], The five crew members and 47 of the passengers on board the plane were bound for Seattle. The pilots decided that Los Angeles looked better. Testimony from the director of reliability and maintenance programs of Alaska Airlines was that a data-analysis package based on the maintenance history of five sample aircraft was submitted to the FAA to justify the extended period between C-checks. The trim might be, and then it might be uh, if somethings popped back there. The airline extended numerous maintenance intervals, while simultaneously skimping on personnel and training. A flight attendant opened the cockpit door, and Captain Thompson briefed her on the situation. [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. The original interval was set at every other C-check or 5,000 flight hours. Contact me via @Admiral_Cloudberg on Reddit, @KyraCloudy on Twitter, or by email at kyracloudy97@gmail.com. In NTSB board member John J. Goglia's statement for the final report, with which the other three board members concurred, he wrote: This is a maintenance accident. 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 mechanic went to federal authorities in late 1998 claiming the airline was cutting back on maintenance and falsifying records to get planes back into operation faster. Eighty-eight people nearly half of them airline employees and some of their families on vacation had lost their lives along with Tansky, Thompson and three flight attendants. [6] Both pilots had previous military experience Thompson in the U.S. Air Force and Tansky in the U.S. Weve run just about everything. They had run out of altitude. Following the crash, families successfully lobbied for design changes and improved airplane maintenance requirements. The airplane immediately began another dive except this time it did not recover. And so began a slash-and-burn cost-cutting campaign a campaign that culminated in a terrible black mark which will forever hang over the company, a tragedy so horrible and so preventable that it would call the safety of the entire industry into question. On board the stricken MD-83, the pilots managed to slow the dive somewhat, pulling up from 70 degrees nose down to 28 degrees, but the plane remained inverted, falling upside down toward the rapidly approaching ocean at a high rate of speed. This is the only time the award has ever been given posthumously. However, only the specimens with no grease mirrored the severe wear rate of the accident airplane. Armed with knowledge of the end play check and the discovery of the slinky the FAA issued an emergency directive for all MD-80 operators to inspect their jackscrews and report any findings. The threads eventually lost up to 90% of their thickness, compared to 22% at the maximum wear depth of one millimeter. 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. The tragedy of 261 forced us to change, he said. He's, ah, down. "[21][22] The aircraft was destroyed by the impact forces, and all occupants on board were killed by blunt-force impact trauma. Despite Alaska Airlines numerous regulatory violations, the investigation ended in 2003 without any charges being filed. Another reported, "Yes sir, ah, I concur. In December of 1998 the federal government launched a criminal investigation into Alaska Airlines, seizing documents and interviewing witnesses. A flight traveling from Mexico crashed into the Pacific Ocean on Jan. 31, 2000. By trimming the stabilizer to (for example) a nose up position, the pilots or the autopilot can keep the plane in a steady climb without touching the controls at all. It looks like hes turning hes turning over in front of you now, said the controller. The aircraft was the 1995th DC-9/MD80 family airframe built,[2] was manufactured and delivered new to Alaska Airlines in 1992, and had logged 26,584 flight hours and 14,315 cycles before the crash. When the stabilizer moves upward, downforce on the tail decreases, and the nose pitches down; similarly, when the stabilizer moves downward, downforce increases, and the nose pitches up. Among major US airlines, Alaska has charted perhaps the most unusual course across its long and fascinating history. National Geographic gets you closer to the stories that matter and past the edge of what's possible through groundbreaking storytelling. Well see you at the gate. This would be the last transmission between flight 261 and Alaska Airlines maintenance. An FAA inspector who reviewed the 1996 extension said that the airline presented only Boeings recently extended lube interval as justification. 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. At 15:49, after flying for two hours with a jammed stabilizer, Thompson and Tansky contacted Alaskas Seattle maintenance base for advice. (To avoid confusion, from here on out nose up and nose down, as they relate to the pitch of the airplane, will be used to describe the stabilizers direction of motion. This caused the stabilizer to pivot upward, thus causing the airplane to pitch down and enter the initial dive (see graphic 7). 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. I need everything picked up and everybody strapped down, he said, cause Im gonna unload the airplane and see if we can gain control of it that way. His intention was to fly at lower speeds where there would be less aerodynamic force pushing up on the stabilizer. Planes inverted sir, a nearby pilot told the controller. I didnt want to call you guys, said the flight attendant, but that girl theyre like, you better go up there and tell them., I need you strapped in, dear, said Thompson, cause Im going to release the back pressure and see if I can get it back.. He is, uh, definitely in a nose down, uh, position, descending quite rapidly. The basis for the approval of the design under this rule was the fact that the nut has two independent threads that did not link with one another, such that if one thread failed, the other could still hold the jackscrew in place. "[13], Steve Miletich of The Seattle Times wrote that the western portion of Washington "had never before experienced such a loss from a plane crash". Laboratory tests indicated that the excessive wear of the jackscrew assembly could not have accumulated in just the four-month period between the September 1999 maintenance and the accident flight. The jackscrew assembly was still attached and jutting out awkwardly (see image 3). Yeah, I heard it, said Thompson. At this time, pilots from aircraft flying in the vicinity reported in, with one pilot saying, "and he's just hit the water." [46][47] The airline retired the last of its MD-80s in 2008 and now uses Boeing 737s and Airbus A320s for these routes.[48]. Season 1 Episode 5 Alaska Airlines Flight 261, a McDonnell Douglas MD-83 aircraft, experienced a fatal accident on January 31, 2000 over the Pacific Ocean. [44][45], As of May 2022, Flight 261 no longer exists, and Alaska Airlines no longer operates the Puerto VallartaSan FranciscoSeattle/Tacoma route. 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. After the flight crew stated their intention to land at LAX, ATC asked whether they wanted to proceed to a lower altitude in preparation for the approach. Im sorry, this airplane isnt gonna go anywhere for a while.. Meanwhile in the cockpit, the pilots tried to figure out what had happened. You got it?. In 1987, Alaska Airlines greased the stabilizer jackscrews on its MD-80s every 500 flight hours, the value recommended by the manufacturer. In July 1988, the airline no longer used a flight hour limit rather it based C-checks on calendar time only so that the end play check was being performed every 26 months. [6]:9[21], The CVR transcript reveals the pilots' constant attempts for the duration of the dive to regain control of the aircraft. A big, huge plunge, thank you, said the controller. The original interval was 500 flight hours (graphic 12). In 1996, Alaska Airlines applied to the FAA to extend the interval between its C-checks from 13 months to 15 months. In August 1999, Alaska Airlines put Liotine on paid leave,[28] and in 2000, Liotine filed a libel suit against the airline. All rights reserved. They wished to avoid the mistakes made by Trans World Airlines in the aftermath of the TWA Flight 800 accident, in other words, TWA's failure to provide timely information and compassion to the families of the victims. Pilots of nearby planes caught sight of flight 261 and radioed Los Angeles air traffic control. The FAA approved the extension without assessing the effect this would have on individual inspection tasks that were tied to the C-check interval. [43], The crash has appeared in various advance fee fraud ("419") email scams, in which a scammer uses the name of someone who died in the crash to lure unsuspecting victims into sending money to the scammer by claiming the crash victim left huge amounts of unclaimed funds in a foreign bank account. Thats affirm, said Thompson. Indeed, by the end of the 1990s, what had once been a small regional carrier had successfully transformed itself into one of Americas largest airlines. If they had not attempted to move the stabilizer immediately before the first dive, their chances of safely reaching an airport before the jackscrew failed entirely would have been much greater. Another reported, "Ah, yes sir, he, ah, he, ah, hit the water. The NTSB believed that this was inappropriate because each airline operates their airplanes under unique circumstances that require unique FAA oversight and data justification regardless of the manufacturers recommended intervals. [12], At least 35 occupants of Flight 261 were connected in some manner with Alaska Airlines or its sister carrier Horizon Air, including 12 actual employees,[13] leading many of the airline's personnel to mourn for those lost in the crash. Flight 261 was traveling from Puerto Vallarta to San Francisco on Jan. 31, 2000 when a mechanical malfunction inverted the jet and sent it downward off the Ventura County coast. 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. This interval was increased again in April 1996 to 30 months equating to about 9,550 flight hours under the airlines accelerated utilization. The base confirmed that there werent any known problems with the stabilizer, and the discussion then turned to how to handle the failure. By 2000, Alaska Airlines only inspected the wear on the jackscrew nut every 30 months, equivalent to 9,550 flight hours, whereas the manufacturer recommended an interval no larger than 7,200 flight hours. But over the next two decades, Alaska Airlines pursued an aggressive strategy of expansion, aiming to become an affordable option for travelers throughout the Western United States. Based on the time since the last inspection of the jackscrew assembly, the NTSB determined that the acme-nut thread had deteriorated at 0.012 inches (0.30mm) per 1000 flight hours, much faster than the expected wear of 0.001 inches (0.025mm) per 1000 flighthours. [6][24], The later analysis estimated that 90% of the thread in the acme nut had already worn away previously and that it had finally stripped out during the flight while en route to San Francisco. The NTSB Maintenance Group and my group examined the accident airplanes records and found that two years earlier, a lead mechanic at the airlines Oakland maintenance facility had found that the jackscrew end play was worn to its maximum limit of 0.040 inch. At their cruising altitude and speed, the position of the jammed stabilizer required the pilots to pull on their yokes with about 10lbf (44N) of force to keep level. Copyright 2023 KABC Television, LLC. [30], The victims' families approved the construction of a memorial sundial, designed by Santa Barbara artist James "Bud" Bottoms, which was placed at Port Hueneme on the California coast. About 70 people gathered at . [6]:9 The crippled plane had been given a block altitude,[20] and several aircraft in the vicinity had been alerted by ATC to maintain visual contact with the stricken jet. Following the procedures prescribed in the checklists, they tried cycling the motors on and off, checking the trim motor circuit breakers, and using the manual trim controls. 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. In fact, by now there were several other airplanes in the area that were keenly watching the unfolding situation. Still, the pilots did not give up; Thompson thought it might be possible to roll out right-side-up using the rudder. What a hard way to die: so an airline can make more money., ________________________________________________________________. ?On January 31, 2000, about 1621 Pacific standard time, Alaska Airlines, Inc., flight 261, a McDonnell Douglas MD-83, N963AS, crashed into the Pacific Ocean about 2.7 miles north of Anacapa Island, California. All large airplanes have what is referred to as a trimmable horizontal stabilizer. It went down, it went to full nose down.. [32][33], Captain Thompson and First Officer Tansky were both posthumously awarded the Air Line Pilots Association Gold Medal for Heroism, in recognition of their actions during the emergency.
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