The Price of an Hour: The crash of Alaska Airlines flight 261

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. This article is written without reference to and supersedes the original.

A still from the TV show “Mayday” attempts to capture the harrowing final moments of Alaska Airlines flight 261. (Mayday)

On the 31st of January 2000, an Alaska Airlines MD-83 bound for San Francisco suddenly plunged from the sky off the coast of California, spiraling downward until it slammed into the Pacific Ocean. The horrific crash killed all 88 people on board and raised troubling questions about one of America’s largest airlines. For two hours, the crew of the ill-fated jet had struggled with a malfunctioning stabilizer, unaware that this critical flight control system had turned into a ticking time bomb counting down toward catastrophic failure. Indeed, the final, terrifying dive was the culmination not just of hours of failed troubleshooting, but of years upon years of negligent maintenance, blatant corruption, and lax federal oversight, a deadly combination that led to an unprecedented failure of the stabilizer trim jackscrew — one of the scariest malfunctions any flight crew has ever faced. 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.

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A quirky advertisement for Alaska Airlines from the ’60s or ’70s. (Alaska Airlines Blog)

Among major US airlines, Alaska has charted perhaps the most unusual course across its long and fascinating history. 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. 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. 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. Indeed, by the end of the 1990s, what had once been a small regional carrier had successfully transformed itself into one of America’s largest airlines.

But this very success may have planted the seeds of the disaster which followed. During the 1990s, low-cost competitors such as MarkAir in Alaska and Southwest Airlines in the Pacific Northwest began trying to undercut Alaska’s more traditional fare model on numerous core routes. In 1991, after posting a record loss of $121 million, the company’s business analysts concluded that to remain competitive, Alaska Airlines needed to reduce expenses. 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.

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N963AS, the aircraft involved in the accident. (User N94504 via Airliners.net)

Nine years after the cost-cutting began, Alaska Airlines was posting profits again, its fleet was expanding, and passenger numbers were higher than ever. The turn of the millennium had just come and gone, and the future again seemed limitless. And so it was that on a sunny day in January 2000, 83 passengers and five crew boarded Alaska Airlines flight 261 in the resort city of Puerto Vallarta, Mexico, bound for San Francisco, California. The eight-year-old McDonnell Douglas MD-83, registered as N963AS, outwardly seemed to be in good shape. The pilots, 53-year-old Captain Ted Thompson and 57-year-old First Officer Bill Tansky, could not have known that they were about to play out the final chapter in a sordid story that had been building toward its conclusion for years.

Indeed, all seemed normal as flight 261 climbed out from Puerto Vallarta, heading for its cruising altitude of 31,000 feet. The Gulf of California stretched out below them, bright and blue. And then, as the plane passed through 23,400 feet, a warning light flicked on in the cockpit: “AUTOPILOT TRIM,” it said. It was the first sign that something was in fact gravely wrong with their airplane.

All large airplanes have what is referred to as a trimmable horizontal stabilizer. 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. 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 don’t have to continuously pull up or push down using the elevators in order to climb or descend. 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.

The basic design of the stabilizer is relatively simple. The stabilizer is attached to a giant threaded screw, called the jackscrew, which feeds through a nut attached to the aircraft structure inside the tail. Two electric motors spin the jackscrew within the nut, causing the stabilizer to move up or down. 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. Mechanical stops attached to the jackscrew prevent the stabilizer from moving farther than 2.5 degrees upward or 12.5 degrees downward. (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 stabilizer’s direction of motion. Keep in mind that the pitch of the stabilizer itself is actually inverse to the pitch of the airplane.)

The jackscrew is one of the few components of the MD-80 series that does not have a redundant backup in case of failure. As such, it is critically important that the jackscrew be kept in good working order, primarily through the liberal application of grease at regular intervals.

The metal from which the jackscrew is made is ever so slightly harder than the metal used in the nut. Over time, this minute difference will cause the jackscrew to wear away the threads on the nut if metal-on-metal contact is allowed to occur. 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.

In 1987, Alaska Airlines greased the stabilizer jackscrews on its MD-80s every 500 flight hours, the value recommended by the manufacturer. But as the airline began cutting costs over the following decade, one of the areas that got put on the chopping block was maintenance. Performing maintenance less frequently saved on labor costs and kept the planes in the air longer, thus increasing revenue. As a result, Alaska Airlines slowly increased the interval between jackscrew lubrications from 500 flight hours in 1987 to every eight months (approximately 2,250 flight hours) in 1999. In theory this was adequate, but only if the grease was applied correctly every time.

A properly greased jackscrew, seen during an inspection for wear. (NTSB)

However, during the 1990s the quality of maintenance at Alaska Airlines began to slip significantly. The airline extended numerous maintenance intervals, while simultaneously skimping on personnel and training. Many of Alaska’s maintenance workers received on the job training only without any formal curriculum. Key safety-related positions within the airline’s management structure went unfilled. Quality control fell by the wayside as workers performed tasks they didn’t understand, while under pressure to get planes back in service as quickly as possible. Technical logs fell through the cracks; critical forms were left incomplete; paperwork was outright falsified to show work done when it was not.

The seemingly simple task of greasing the jackscrew was not immune to this degradation of the maintenance environment. According to the official maintenance manual, greasing the jackscrew involved three main steps. First, pressurized grease was to be injected into a special tube on the nut until it filled all the thread gaps between the nut and the jackscrew and started to bulge out the top. Then, additional grease was to be applied to the entire length of the screw, filling all the threads. Finally, the stabilizer was to be moved repeatedly between full nose up and full nose down so that the nut could spread the grease evenly over the entire jackscrew.

If done correctly, the process took about four hours. However, Alaska Airlines maintenance personnel often did it in as little as one hour — not because they found a more efficient way, but because they didn’t understand the proper procedure and skipped some of the steps. Many workers who greased jackscrews didn’t apply additional grease to the screw itself after greasing the nut. Some did still less, failing even to ensure that grease totally filled the inside of the nut. The result was a chronic problem of Alaska Airlines MD-80s with poorly greased jackscrews. And because of the increased interval between applications of new grease, a jackscrew with insufficient grease couldn’t expect to see more until the plane had been in the air for another 2,250 hours.

The problem was that with insufficient grease, the threads on the nut began to wear down at an accelerated rate. With no grease at all, the rate of wear would increase by a factor of ten or more. In order to catch abnormal wear before it escalated to the point of failure, MD-80 operators regularly inspected their stabilizer jackscrew nuts to ensure that the wear remained within limits. (Alaska specifically did this every 30 months, or 9,550 flight hours.) By torqueing the screw up and down without turning it, and measuring the amount of play in the system, it was possible to roughly determine the depth of the wear on the nut threads, which the manufacturer’s guidelines stated must be less than one millimeter. Anything more than that and the nut would need to be replaced. But the measurements were imprecise and repeated tests often produced different results — allowing a certain amount of ambiguity as to whether the value was over or under the limit. N963AS, the plane that would later become Alaska Airlines flight 261, was one of many in the airline’s fleet that was subject to these marginal maintenance practices.

In September of 1997, maintenance workers in Oakland performed the aforementioned test on N963AS and found a wear depth of exactly one millimeter. The lead mechanic that day was John Liotine, a rare Alaska Airlines employee who still took safety seriously. When he measured the wear on the jackscrew nut and found it to be exactly one millimeter (0.040in), he concluded that the nut had reached the end of its service life and issued a work card ordering its replacement. 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. The night shift subsequently performed the test five more times and measured a wear depth of approximately 0.84mm on each attempt. On the basis of these measurements, the shift supervisors overruled Liotine’s earlier work order and cleared the plane to fly. That was the last time anyone ever measured the wear on the jackscrew nut on N963AS.

The actual work card related to the fateful jackscrew nut inspection, 27 Sept. 1997. (NTSB)

In 1998, fed up with a maintenance environment that did not seem to prioritize safety, John Liotine blew the whistle and alerted the FAA to some of Alaska’s numerous violations. For several months he surreptitiously recorded his bosses violating safety rules and handed the tapes over to FAA investigators. In December of 1998 the federal government launched a criminal investigation into Alaska Airlines, seizing documents and interviewing witnesses. Then in 1999 Alaska Airlines retaliated against John Liotine, putting him on indefinite leave from his job and circulating false rumors about him; the airline sought to portray him in the media as a “disgruntled employee” who wanted to get back at supervisors who passed him over for promotion.

Meanwhile, N963AS continued to fly, and maintenance workers continued to grease the jackscrew every eight months. However, the plane ran into a streak of at least two or three grease applications that were not done correctly, including one in September 1999 by a notorious San Francisco-based mechanic who was later found to have applied virtually no grease to any of the jackscrews he worked on. The longer it went without being greased properly, the faster the jackscrew wore down the threads on the nut. The threads eventually lost up to 90% of their thickness, compared to 22% at the maximum wear depth of one millimeter. It was on board Alaska Airlines flight 261 from Puerto Vallarta to San Francisco on the 31st of January 2000 that this sequence of events that had been years in the making finally came to its terrifying conclusion.

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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. Four minutes later, a warning light illuminated to inform the crew that the autopilot was unable to move the stabilizer. Pilots Thompson and Tansky disconnected the autopilot to see what they were up against, and found that the stabilizer had jammed slightly nose down, requiring constant force on the elevators to overcome it and continue climbing.

As any good crew should do, Thompson and Tansky then pulled out the checklists for a runaway or inoperative stabilizer. 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. Neither the electric switches (which the pilots called “pickle switches”) nor the fully manual trim handles (referred to as the “suitcase handles”) could move the stabilizer. At this point the checklist said “Consider stab jammed, do not use autopilot,” and offered a list of considerations to be made during landing.

In hindsight, the crew should have turned around and immediately landed back in Puerto Vallarta. Lives would have been saved if they had. But neither of the applicable checklists said anything about landing at the nearest available airport, and by the time they finished the checklists and leveled off at 31,000 feet, minimal effort was required to keep the plane flying level. As far as the pilots were concerned, the electric motors had probably seized and they could fly on to San Francisco without trimming the stabilizer. They had no way of knowing at this stage that the problem was mechanical in nature.

At 15:49, after flying for two hours with a jammed stabilizer, Thompson and Tansky contacted Alaska’s Seattle maintenance base for advice. The base confirmed that there weren’t any known problems with the stabilizer, and the discussion then turned to how to handle the failure. Within the next several minutes the pilots expected to pass abeam Los Angeles off the coast, and they were strongly considering a diversion to LAX, given that none of their troubleshooting had fixed the problem. But airline dispatchers in Seattle were less keen on this idea and preferred that flight 261 continue to San Francisco as scheduled. Captain Thompson argued that conditions would be more suitable for landing at Los Angeles, and the dispatcher admitted that the reason they preferred San Francisco was because a diversion would disrupt “flow,” worsening mounting delays in Alaska’s flight schedule. Captain Thompson was not happy with this reasoning.

“I really didn’t want to hear about flow being the reason you’re calling us,” he said to the dispatcher, “Cause I’m concerned about overflying suitable airports.”

“Well we want to do what’s safe,” said the dispatcher, “so if that’s what you feel is safe… we just want to make sure you have all the info.”

The pilots asked for information on the runway conditions in San Francisco, and the dispatcher temporarily signed off to go find some. No decision was made at this point about whether or not to divert. On board flight 261, Captain Thompson vented to First Officer Tansky: “…Drives me nuts,” he said. “Not that I want to go on about it… you know, it just blows me away they think we’re gonna land, they’re gonna fix it, now they’re worried about the flow. I’m sorry, this airplane isn’t gonna go anywhere for a while.”

“So they’re trying to put pressure on you,” said Tansky.

“Well, no, yeah,” said Thompson.

At 15:55, the dispatcher returned with wind speeds, wind directions, and runway conditions at San Francisco and Los Angeles. The pilots decided that Los Angeles looked better. “We’re going to LAX,” Thompson told the dispatcher. “We’re gonna stay up here and burn a little more gas, get all our ducks in a row, and then we’ll be talking to LAX when we start down to go in there.” The plan was to stay on course a little longer, burning fuel to reduce their landing weight and test out the plane’s handling capabilities, before turning around and heading into Los Angeles. The pilots didn’t want to discover on final approach that the plane was uncontrollable at low speeds. 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.

At 16:07, flight 261 contacted Alaska Airlines’ Los Angeles maintenance facility on the radio. “You did try the suitcase handles and the pickle switches, right?” the maintenance technician asked.

“Yeah, we tried everything together,” said Thompson. “We’ve run just about everything. If you’ve got any hidden circuit breakers we’d love to know about ‘em.” Over the next couple minutes the pilots reported to maintenance that electrical current was present when they activated the trim motors, but that the motors nevertheless could not move the stabilizer.

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. At 16:09, he said, “I’m gonna click it off. You got it?”

“Okay,” said Tansky.

“Let’s do that.” Thompson attempted to move the stabilizer trim using either the electrical switches, the trim handles, or both, in an effort to clear the jam. The effect was immediate and catastrophic, as his inputs ripped out whatever threads remained on the jackscrew nut. 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. With the stabilizer angled 3.1 degrees toward nose down, more than the design maximum of 2.5 degrees, flight 261 immediately entered a high-speed dive, hurtling downward at more than 6,000 feet per minute.

In the cockpit, the pilots heard a loud clunk followed by two thumps, and the plane pitched steeply downward. The crew scrambled to react to the massive upset. “Holy shit,” said Thompson, pulling back hard on the controls. “You got it? Fuck me!”

“What are you doing?” Tansky asked.

“I clicked it off,” Thompson said. “It got worse, okay.” Violent vibrations shook the airplane.

As they struggled to regain control, Thompson radioed Los Angeles and said, “Center, Alaska two six one, we are in a dive here, and I’ve lost control, vertical pitch!” An overspeed warning blared in the cockpit.

“Alaska two sixty one, say again sir,” said the controller.

“Yeah, we are out of 26,000 feet, we are in a vertical dive… not a dive yet, but uh, we’ve lost vertical control of our airplane.”

However, slowly but surely, Thompson and Tansky started to rein in their excessive speed and flatten out the slope of the dive. “We are at twenty three seven, request, uh,” Thompson said to the controller. “Yeah, we got it back under control here.”

“No we don’t,” said Tansky.

By now the plane had leveled out at about 23,500 feet, after plunging 7,500 feet in 80 seconds. Only by applying a continuous maximum nose up elevator input on his control column, a task which required enormous physical effort, was Captain Thompson able to maintain level flight.

“Fuck me,” he said. “It really wants to pitch down.”

“Okay,” said Tansky.

“Don’t mess with that,” said Thompson.

“I agree with you.”

“Alaska two six one,” said the controller, “Say your condition?”

“Two six one, we are at 24,000 feet, kinda stabilized,” said Thompson. “We’re slowing here, and we’re gonna do a little troubleshooting, can you give me a block altitude between twenty and twenty five?”

The controller granted the block altitude. By requesting any altitude between 20,000 and 25,000 feet, the crew of flight 261 could ensure that if they nosedived again, nearby planes wouldn’t be in danger. In fact, by now there were several other airplanes in the area that were keenly watching the unfolding situation.

“You have the airplane. Let me just try it,” Tansky said, offering to take over the strenuous task of holding the plane level.

“Okay,” said Thompson.

“Uh, how hard is it?” Tansky asked.

“I don’t know, my adrenaline’s going,” said Thompson. “It was really tough there for a while.”

“Whatever we did is no good, don’t do that again,” said Tansky.

“Yeah, no,” said Thompson. “It went down, it went to full nose down.”

“Uh, it’s a lot worse than it was?” Tansky asked.

“I think it’s at the stop, full stop,” said Thompson. “I’m thinking, can it get any worse, but it probably can,” he continued. “But when we slowed down… let’s slow it, let’s get it down to two hundred knots and see what happens.”

Map of the final part of the flight. (FAA)

Now Thompson and Tansky slowed down and deployed the flaps and slats, simulating a landing configuration, to make sure the plane would be controllable on final approach. While Tansky held the plane steady, Thompson contacted LAX maintenance again. “We did both the pickle switches and the suitcase handles,” he told the maintenance technician, “and it ran away full nose trim down.”

“Oh, it ran away trim down?”

“And now we’re in a pinch,” Thompson continued, “so we’re holding, uh, we’re worse than we were.”

“Uh, you getting full nose trim down but are you getting any… you don’t get no nose trim up, is that correct?” maintenance asked.

“That’s affirm,” said Thompson. “We went to full nose down and I’m afraid to try it again to see if we can get it to go in the other direction.”

“Okay, well, your discretion,” said maintenance. “Uh, if you want to try it, that’s ok with me, if not, that’s fine. We’ll see you at the gate.” This would be the last transmission between flight 261 and Alaska Airlines maintenance.

Meanwhile in the cockpit, the pilots tried to figure out what had happened. “Did it happen… went in reverse?” Tansky asked.

“I went tab down, right, and it should have come back. Instead it went the other way.”

“Uh huh.”

“What do you think. You want to try it or not?”

“Uh, boy, I don’t know,” said Tansky.

“It’s up to you, man,” said Thompson.

“Let’s head back,” Tansky suggested.

Keying the public address system, Captain Thompson announced, “Folks, we have had a flight control problem up front here; we’re working it… Uh, that’s Los Angeles off to the right there, that’s where we’re intending to go. We’re pretty busy up here working this situation. I don’t anticipate any big problems once we get a couple of sub systems on the line. But we will be going into LAX, and I’d anticipate us parking there in about twenty to thirty minutes.”

Having decided not to touch the trim system anymore, the crew now performed some final tests of the airplane’s low speed handling. Los Angeles controllers gave flight 261 permission to approach the airport, but Thompson asked to stay out over the ocean while they tested the controllability of their airplane. If they lost control again, he didn’t want to endanger people on the ground.

A flight attendant opened the cockpit door, and Captain Thompson briefed her on the situation. “I need everything picked up and everybody strapped down,” he said, “cause I’m 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. By this point the amount of force he needed to apply to the control column to keep the nose level was pushing him to the limit of his physical ability.

“Okay, we had a big bang back there,” said the flight attendant.

“Yeah, I heard it,” said Thompson. “The stab trim, I think.”

“You heard it in the back?” Tansky asked.

“Yeah.”

“I think the stab trim thing is broke,” said Thompson.

“I didn’t want to call you guys,” said the flight attendant, “but that girl — they’re like, you better go up there and tell them.”

“I need you strapped in, dear,” said Thompson, “cause I’m going to release the back pressure and see if I can get it back.”

How aerodynamic forces were affecting the badly damaged horizontal stabilizer. (Own work)

Over the next couple minutes, the pilots found the plane to be reasonably stable at lower speeds. Thompson continued to think about ways to unjam the stabilizer. “What I want to do is get the nose up, and then let the nose fall through and see if we can stab it when it’s unloaded.” It was his belief that the stabilizer might move nose up if there was no aerodynamic force pushing it upward into the nose down position.

“You mean, use this again?” Tansky asked, presumably pointing at the trim switches. “I don’t think we should, if it can fly, it’s like — ”

“It’s on the stop now, it’s on the stop,” Thompson said.

“Not according to that it’s not,” said Tansky. “The trim might be, and then it might be uh, if something’s popped back there…”

“Yeah.”

“It might be mechanical damage too. I think if it’s controllable, we ought to just try and land it,” said Tansky.

In the ten minutes that had passed since the dive, the stabilizer had been held at 3.1 degrees nose down by nothing more than the mechanical stop on the bottom of the jackscrew. The massive aerodynamic force pushing up on the horizontal stabilizer was normally absorbed by the nut, but with its threads stripped, all that force was transmitted through the mechanical stop instead. It was not designed to handle that kind of pressure, and over those ten minutes, it started to fracture. Finally, at 16:19 and 21 seconds, the stop gave way with a faint thump.

“You feel that?” Tansky asked.

“Okay, give me sl — see, this is a bitch!” said Thompson.

The entire horizontal stabilizer assembly was now attached to the airplane only by the rear hinge. The free-swinging stabilizer rotated up past its stop, slamming back against the aerodynamic fairing that encased the tail. Three seconds later, the fairing failed, and the stabilizer swung unimpeded on its hinge to a position of at least 14 degrees aircraft nose down. Flight 261 immediately plunged into a near-vertical dive, hurtling downward toward the Pacific Ocean.

As Thompson fought with all his might to regain control, Tansky shouted “Mayday!” but forgot to key his mic. A cacophony of banging and roaring filled the cockpit. The pilots pulled back as hard as they could on their control columns and deployed the flaps to try and slow down, but their efforts were utterly hopeless.

Pilots of nearby planes caught sight of flight 261 and radioed Los Angeles air traffic control. “That plane just started to do a big, huge plunge,” said one pilot.

“A big, huge plunge, thank you,” said the controller. “SkyWest 5154, the MD-80 is one becoming two o’clock about ten miles now. Another pilot reports he’s really looking pretty bad there, ahead and to your right, do you see him?”

“Yes sir, I concur,” said the SkyWest pilot, “He is definitely in a nose down position descending quite rapidly.”

Flight 261 started to corkscrew, pirouetting and rolling inverted as it fell. “Push and roll! Push and roll!” Thompson shouted, trying to coordinate with Tansky to roll the plane right-side-up. “Okay, we are inverted, and now we gotta get it…”

“Plane’s inverted sir,” a nearby pilot told the controller.

“It looks like he’s turning… he’s turning over in front of you now,” said the controller. “SkyWest 5154, you still got your eyes on him, sir?”

“He’s in sight, he’s, uh, definitely out of control,” said the SkyWest pilot.

This animation of flight 261’s final dive was featured in Mayday: Season 1 Episode 5, “Cutting Corners.”

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. Still, the pilots did not give up; Thompson thought it might be possible to roll out right-side-up using the rudder.

“Kick!” he shouted. “Push push push, push the blue side up!”

“I’m pushing!”

“Okay, now let’s kick rudder, left rudder, left rudder…”

“I can’t reach it!” said Tansky. Stepping on the rudder pedals while upside down was no easy task.

“Okay, right rudder, right rudder,” said Thompson. Still flying inverted, the plane leveled further, to nine degrees nose down. “Are we flying?” he said. “…We’re flying… we’re flying… tell ’em what we’re doing.”

“Oh yeah, let me get…” said Tansky. He opened the mic for the public address system but never managed to get any words out.

“Gotta get it over again…” said Thompson. “At least upside down, we’re flying!”

An airliner cannot truly fly upside down — maintaining level flight in such a condition is essentially impossible, and the engines will quickly die — but if anyone ever came close, it was Captain Thompson and First Officer Tansky as they heroically tried to save their stricken aircraft, even after all hope was lost.

Watching the death throes of flight 261, the SkyWest pilot told controllers, “Yeah, he’s inverted.”

“Okay,” said the controller, apprehension evident in his voice. “Just do what you need to do there, SkyWest 5154. Keep us advised.”

Still descending at high speed, flight 261’s engines proved unable to keep combustion going in such an unusual attitude and started to stall with a series of loud bangs.

“Speedbrakes!” Captain Thompson called out, still trying to find ways to arrest the dive.

“Got it,” said Tansky.

But there was nothing to be done. They had run out of altitude. “Ah, here we go,” said Captain Thompson, uttering the last words captured on the cockpit voice recorder. Less than one second later, Alaska Airlines flight 261 slammed into the Pacific Ocean, obliterating the aircraft and instantly killing all 88 people on board.

Badly shaken witnesses reported the crash to air traffic control within seconds. “And he’s just hit the water,” said one pilot.

“Yes sir, he… he hit the water,” said the SkyWest pilot, his voice nearly cracking. “He’s ah, down.”

Rescue vessels raced to the crash site three kilometers east of Anacapa Island in the Santa Barbara Channel, hoping to find survivors. Instead, all they could find was an oil slick and some light floating debris. It was clear that nobody had survived the crash. By nightfall, working with the help of flood lights from squid fishing boats, recovery workers managed to find just seven bodies. Salvage vessels had to be brought in to raise the rest of the plane from the bottom of the Pacific Ocean.

As investigators recovered more and more of the plane from the ocean floor, a troubling picture of the sequence of events began to emerge. When the jackscrew was hauled to the surface, investigators could not find any trace of grease on it, except for some old, dried out leftovers outside the normal working area of the screw. The tangled remnants of the threads from the nut remained wrapped around the jackscrew, wordlessly telling the story of how the stabilizer failed. That was the how — but the bigger question was why.

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The investigation uncovered a daunting list of operational problems and regulatory mistakes that led to the crash. Most importantly, the National Transportation Safety Board excoriated Alaska Airlines’ decision to increase the intervals between jackscrew lubrications and wear inspections, and the FAA’s approval of these intervals, which it considered to be a direct cause of the accident. 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. N963AS nearly made it anyway — its next jackscrew inspection was scheduled for March 2000. Had it been inspected after 7,200 flight hours instead of 9,550, the excessive wear would have been discovered before the crash.

The Safety Board found that this unsafe inspection interval was only approved indirectly by the FAA. 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. In 1996, Alaska Airlines applied to the FAA to extend the interval between its C-checks from 13 months to 15 months. The FAA approved the extension without assessing the effect this would have on individual inspection tasks that were tied to the C-check interval. Therefore the interval between jackscrew inspections was effectively increased from 26 to 30 months without the FAA spending a single minute looking into whether or not this was appropriate.

And therein lay the problem: throughout the period leading up to the crash, Alaska Airlines slowly removed all the procedural layers of redundancy which were designed to prevent the jackscrew from deteriorating to the point of failure. Increasing the interval between lubrications meant that every lubrication had to be done correctly in order to prevent accelerated wear and tear. And at the same time, the increased inspection interval meant that it was now possible for a jackscrew nut to pass an inspection, later receive inadequate lubrication, and then wear down to the point of failure, all before the next inspection came around. The only layer of protection against a catastrophe was therefore the assumption that poorly trained, low-paid maintenance workers would apply enough grease. Tragically, they didn’t.

A special inspection by the FAA after the accident found further evidence of a massively deficient safety culture at Alaska Airlines. The FAA’s special inspection report noted that the position of Director of Maintenance had gone unfilled since 1998; the Director of Operations position was empty; the Director of Safety was also the Director of Quality Control and the Director of Training and didn’t report to high-level management; there was no maintenance training curriculum; on-the-job training was completely unstructured; the procedures in use didn’t match those outlined in the maintenance manual; planes had been released from C-checks with paperwork incomplete; perishable and consumable materials had expired; shift turnover paperwork was missing, unsigned, or incomplete; work cards were not filled out properly; and more — the list went on and on. It was no wonder, given these findings, why Alaska Airlines mechanics didn’t know how to grease the jackscrew, and why nobody held them accountable for not doing so properly.

Wreckage from the plane was collected in a hangar for sorting and analysis. (Mike Nelson)

The Safety Board also examined the design of the jackscrew itself, and found that it probably didn’t meet certification standards. The problem, again, was a lack of redundancy: if the threads on the nut failed, there was no other structure that could absorb the load, and the catastrophic failure of the trim system leading to the loss of the airplane was inevitable. The design of the jackscrew on the MD-80 series was identical to that of the original 1960s-era Douglas DC-9, which was certified to meet requirements stating that no “reasonably probable” single failure of the control system could jeopardize the controllability of the airplane. 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. However, this premise was based on the assumption that one of the threads might separate from the nut due to metal fatigue or improper workmanship, and did not consider the possibility of abnormal wear simultaneously compromising the strength of both threads. Thus the fundamental principle of redundancy was violated.

Wreckage was labeled to aid in its reconstruction. (Bryan Chan)

Finally, the Safety Board also felt that there were lessons to be learned from the actions of the pilots. The report noted that the crash could have been avoided if they had immediately returned to Puerto Vallarta when they encountered the jammed stabilizer. However, the procedures available to them did not state that this was necessary, which doubtlessly contributed to their decision to continue on. More importantly, investigators felt that the pilots should not have attempted to troubleshoot the problem after exhausting the procedures in the checklist, considering that they didn’t know the extent of the damage. 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.

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. Furthermore, the pilots were reluctant to believe that the failure was mechanical, rather than electrical, in nature. All of these factors could have contributed to their decision to troubleshoot a problem that was best left alone. Nevertheless, investigators praised the pilots for their heroic last-ditch efforts to save their aircraft, even attempting to fly upside down when they found they could not level the plane. Both Captain Thompson and First Officer Tansky posthumously received the Air Line Pilots Association Gold Medal for Heroism.

The horizontal stabilizer was, of course, the star of the investigation. (Mike Nelson)

As the NTSB investigation continued, so too did the criminal investigation and the saga of John Liotine. Shortly after the accident, Liotine discovered that the jackscrew nut he had inspected in 1997 was not in fact replaced and had actually gone on to cause the crash. The anger he must have felt is difficult to fathom. 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. But in the end he was forced to accept a mere $500,000 settlement, far less than the $20 million he had sought, and only then on the condition that he resign from his job. Alaska Airlines had hung him out to dry, and to add insult to injury, his blowing the whistle failed to prevent the crash of flight 261. The whole episode must have left him a bitter man — although unlike most whistleblowers, he did manage to restart his career in the industry.

The criminal investigation also proved to be a disappointment. Despite Alaska Airlines’ numerous regulatory violations, the investigation ended in 2003 without any charges being filed. The airline ended up being fined a mere $44,000 for allowing planes to fly 840 times without properly completed maintenance records. The outcomes of wrongful death suits against Alaska filed by the victims’ families are unknown, but it has been reported that the airline eventually settled with the families out of court for a total of at least $300 million, all of which was covered by insurance.

During the course of the investigation and in its final report, the NTSB issued a large number of recommendations, including that the lubrication procedure for the MD-80 series jackscrew be revised; that a more accurate method of measuring wear on the jackscrew be developed; that maintenance technicians be specifically taught how to grease and inspect jackscrews; that the FAA not approve lubrication interval extensions without the airline providing supporting data; that all airlines be surveyed to ensure compliance with jackscrew lubrication procedures; that a bulletin be issued instructing pilots not to troubleshoot inoperative flight controls; that maintenance personnel and dispatchers be trained not to suggest continuation of a flight that is experiencing a major malfunction; that the jackscrew be made easier for maintenance workers to access; that an inspector be required to sign off on every lubrication of the jackscrew; that all maintenance intervals for critical components be re-examined based on data analysis to ensure that they are not too long; that the application process for maintenance interval changes be reformed; that MD-80 series jackscrew inspections be made on a tighter schedule; that some failsafe mechanism be incorporated to ensure the redundancy of the MD-80 jackscrew; and that the FAA ensure future stabilizer designs can’t have a single point of failure. Almost all of these recommendations were implemented.

Recovery crews pull wreckage from the Pacific Ocean. (US Coast Guard)

Following the crash and the damning FAA special inspection report, Alaska Airlines overhauled its maintenance program, including through its compliance with a new FAA airworthiness directive mandating that the jackscrew lubrication interval not exceed 650 flight hours. 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. But the mechanism by which Alaska Airlines fell to such a dismal level of safety is not entirely gone. FAA employees charged with overseeing safety compliance at Alaska before the crash complained that they did not have sufficient staff to closely track its operations, which doubtlessly contributed to the airline’s ability to keep woefully deficient maintenance practices under the radar of the federal government. And more than 21 years after the crash of flight 261, it is far from clear that the FAA is any less understaffed than it was when it let safety at Alaska Airlines fall to pieces at the cost of 88 lives. The US aviation industry has nevertheless managed to go a long time without another major crash, but as for whether something like Alaska 261 could happen again — well, never say never.

Family members gather at the monument to the victims, erected in the town of Port Hueneme, California, near the crash site. The monument forms a sundial, which casts a shadow on the memorial plaque every January 31st at precisely 4:22 p.m., the time of the crash. (Ventury County Star)

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. This was not one of those cases. The last minutes of those on board the doomed MD-83 would have been sheer hell, as the plane went inverted, corkscrewed, pirouetted, and spun like a top during its final dive. For the relatives of the victims, this fact made it all the more important that Alaska Airlines pay for its negligence. But in the end, Alaska all but got away with it. 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 Alaska’s lawyers tried to downplay the monetary value of their deceased loved ones. It’s an outcome that has left many of them bitter to this day. As Fred Miller, father of crash victim Abby Miller-Busche, put it in a 2003 interview, “It seems like such an unholy type of loss. What a hard way to die: so an airline can make more money.”

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Analyzer of plane crashes and author of upcoming book (soon™). Contact me via @Admiral_Cloudberg on Reddit or by email at kylanddempsey@gmail.com.

Analyzer of plane crashes and author of upcoming book (soon™). Contact me via @Admiral_Cloudberg on Reddit or by email at kylanddempsey@gmail.com.