Crash of Alaska Airlines Flight 261
On 31 January 2000, The Alaska Airlines Flight 261 crew, miles above the Pacific, alone with a mechanical hitch, tried doing everything to save their plane as it rolled back and forth to a crash. The pilots of the flight were veterans and both had accumulated thousands of hours flying MD-80’s. Neither of them was involved in an accident before. Departing from Mexico heading to San Francisco International Airport, the flight crew radioed the control facilities to report a jammed horizontal stabilizer and diversion. This stabilizer affected the Trim system, which keeps the plane stable in flight. Neither of them could determine the cause of the jam and repeated attempts to overcome it were unsuccessful (NTSB 2001). Its Captain, Ted Thompson, last words were recorded for nineteen seconds on the Cockpit voice recorder saying, “ Got to get it over again- at least upside down we’re flying”. As he spoke, the mighty plane with 88 occupants was rolling and accelerating downwards very fast that all of them were pressed upwards. In this essay, I will specifically explore and discuss issues related to factors besides technical failures, which all combined to bring about the crash. The CVR transcript reveals that the pilots continuously attempted to control the aircraft. However, the aircraft was far beyond and impacted the pacific at high speed about 14 miles offshore (NTSB 2001).
The National Transportation and Safety Board wrote a report on the accident revealing multiple of maintenance problems even prior to the Crash of Plane Flight 261. Often, an analysis of such accidents revolves on mechanics, final operators, or point failure. In any organizational system, underlying dangerous conditions, if left unmonitored, are capable of becoming a culture. However, it is often these organizational conditions are the most responsible for allowing a gap for creation of a disastrous environment.
Applying this logic to the crash of Flight 261, we ought to believe that such pervading conditions, precisely, led to its horrific end. In general, the dynamic relationship between internal and external pressures and effect can be seen as a continuum between safety and performance (FAA 58). For lower management, increased emphasis on higher performance is always found in the resources allocation, away from security, maintenance, as well as other safety measures. Once a accident occurs, policies will be put in place, defenses put up, and personnel hired (NTSB 2001). However, in time, this emphasis on safety will give way to performance and the chain will continue. Flight 261, both in terms of ultimate outcome and systemic issues, stands out to these accidents effecting from organization system failures (NTSB 2001).
While placing blame of the crash on technical malfunction- according to NTSB report- it is much easier understanding that it does not address the root cause in the System’s defenses breakdown. Due to a number of human errors spanning all of the organization echelons, by the time of the crash of Flight 261, these defenses were unmonitored , stretched and circumvented too thin to be effective (NTSB 2001). In order to determine the main cause of the crash of Flight 261, one has to consider also the environment that the plane operated in. The airline industry is watched by the Federal Aviation Administration, which acts as its own system of checks and balances. They always act as watchdogs over the airline industry. The airlines themselves, with the fundamental basis of success, are always under pressure from time and money management to capitalistic market forces. With the expansion of Alaska just prior to Flight 261 crash, these pressures were compounded aggressively.
Just to keep up with the market the Alaska airlines had to have more airplanes as possible operational at a given time (FAA 58). This constant pressure for performance together with the lack of tangible results provided by the safety measures, created a focal point of pressure to AMS (Aviation Management systems) to work for Alaska as well as other airlines. The highest level in the aviation industry is the FAA, which is responsible for oversight of all United States public airport, airlines, and airplane and airplane parts manufacturers. They provide this oversight by means of providing stringent manuals for maintenance, operations, and other protocols. However, their power is limited since they are responsible for providing oversight but without the power to implement their decisions. This is lack of explicit authority results to airlines and airlines manufacturers to incorporate the FAA policies themselves into their separate maintenance manuals.
A systemic problem that occurred in Flight 261 is clearly seen resulting from the FAA lax oversight, evident in the conversations with other parties involved with Aviation Management systems and the Alaska Airlines. Due to this highly publicized Flight 261 crash, the FAA did an audit of Alaska Airlines exposing serious deficiencies existing for months within the Alaska Maintenance program (FAA 58). These deficiencies existed but were undetected by the FAA. This is probably from the fact that their technicians had no authority under the regulations to check on completed work with the inspectors and mechanics from AMS. An increase in FAA presence was requested by the Alaska Airlines, to meet the increasingly inspection numbers from the growing operations (FAA 58).
Flight 261 inspections revealed that one reason why they were unable to recognize the damage to the Jackscrew assembly is that it was manufactured in-house and was not as accurate as models from the manufacturers themselves. The FAA, when questioned regarding this, responded that such equipment equivalency determination is the responsibility of the air carrier or the repair station and not the FAA (NTSB 2002). When dealing with regulations, it is also evident that the FAA’s lack of oversight led to complacency.
Even though, we cannot blame the fate of Flight 261, on the FAA’s oversight failures as much as they contributed to it. Latent conditions contributing to the crash, for instance, can be traced back to the original Jackscrew manufacturer (Peacock Engineering- acquired by Trig Aerospace). The jackscrew assembly had been installed years before the crash – same economic forces underlying affected this manufacturer too. The manufacturers of jackscrew assemblies, just like the FAA, placed the safety and maintenance onus on the airlines rather than themselves. The investigation by the NTSB that followed the crash resulted to twenty-seven of Alaska Airlines planes to be grounded due to potential Jackscrew mechanism problems. Placing the responsibility to these airlines, clearly, is not adequate solution for safety (Conrad 49).
The systemic issues within the airline that led to the crash was as a result of a culture adopted to centre operational performance at the expense of safety, due to the long periods of safe operations. All necessary defensive barriers, as noted by analysts, were established in Alaska’s system. Over time, however, this focus on safety deteriorated giving way to the performance need, diffusing safety elements (FAA 58). Much as with the airline themselves, the FAA, the jackscrew assembly manufactures, and the economic pressures in the Airline industry combined leading to safety for performance sacrifice within the Alaska Airlines. The NTSB, during its analysis of practices that the Alaska Airline maintenance staff employed, starling discrepancies were found between the Boeing manufacturer data, FAA regulations and even the airline’s own General Maintenance Manual. The NTSB also found that the facilities for maintenance used shop-made tools, relative to the jackscrew assembly, to undertake the invasive play check scrutiny to determine thread wear (FAA 58). This is relative to the nut’s design wear limit. Alaska Maintenance crew, when questioned, told the board that they will continually measure the jackscrew till the required answer was found and produced. As described, they made their own tools to enable them perform and play checks instead of purchasing more expensive, but accurate Boeing-manufactured tools (FAA 58).
To be able to overcome the dangers in the airline industry the focus of the NTSB should be implementing safety management systems, to ensure recognition, confrontation and repair of holes that develop in the defensive layers (Conrad 96). Safety should be seen a value that is core-productive and as such a value that will bring about good reputation and benefit both all the stakeholders involved(FAA 58).
Herein, lies the lesson learnt from the Alaska Airplane Flight 261 crash. As long as accidents and risks are perceived as events that are singular and needs correction, the pervasive conditions underlying which facilitated the organizations defenses breach will remain unchanged. Only after a comprehensive perspective is put in place and adopted can the true problem be discovered. These risks can be overcome by techniques on standard mitigation (FAA 58).
Federal Aviation Administration. “Federal Aviation Administration.” May 2006. Airports . 11 11 2018 <www.faa.gov>.
Ayer, Bill. “Airline Mechanic Admits Falsfying Work Records.” Alaska’s World (2001): 01 – 45.
National Transportation Safety Board., “American Airlines Inc.” 2006. uni-bielefeld. 11 11 2018 <www.rvs.uni-bielefeld.de>.
Conrad, Don. “Metal of honor: Flight 261 Pilots Earn Rare Commendation From ALPA.” People (2001): 4 -96.