By Timothy R. Gaffney tgaffney@daytondailynews.com

August 6, 2003

WASHINGTON | Failure to secure a bolt caused the fatal crash of a Dayton-

based Emery Worldwide Airlines cargo jet more than three years ago, a federal

safety panel ruled Tuesday.

The National Transportation Safety Board's investigative team had focused on

the bolt and related maintenance issues through most of its inquiry into the

Feb. 16, 2000, crash near Sacramento, Calif.

But precisely when the maintenance failure happened and who was responsible —

Emery's own mechanics or a contractor — remains a mystery.

The DC-8 airliner crashed on Feb. 16, 2000, in Rancho Cordova, Calif., two

minutes after takeoff on a flight bound for its Dayton hub. All three

crewmembers died — Capt. Kevin Stables, 43, of Berlin, N.Y.; First Officer

George Land, 35, of Placerville, Calif.; and Second Officer Russell Hicks,

38, of Sparks, Nev.

The pilots fought to control the plane from the moment it took off until it

plunged into a closed auto-auction yard, carving a fiery swath where hundreds

of people had stood hours earlier.

In Tuesday's meeting, the NTSB's five members unanimously adopted their

staff's findings, including one that a bolt connecting part of the plane's elevator-control system worked its way out, causing the elevator to jam in a way that forced the plane into an extreme nose-up position as it took off.

Investigators said a maintenance contractor, Tennessee Technical Services of

Smyrna, Tenn., had replaced the plane's elevators in November 1999, about

three months before the crash. But they also learned Emery maintenance

personnel had worked on the plane's elevator at least twice before the crash.

Investigators found Emery's maintenance documents too fuzzy to determine just

who did what — or even what was supposed to have been done.

"There was insufficient evidence for (the NTSB) staff to determine exactly

when or how the bolt was improperly secured," said Frank Hilldrup, the

board's staff investigator in charge of the inquiry.

"This event was a tragedy," NTSB Chairwoman Ellen G. Engleman said. "It

illustrates the interdependence and critical roles and responsibilities of

each member of the aviation safety chain. Safety requires 100 percent

performance by everyone."

The ruling concluded the board's investigation of an accident that came

amidst Emery pilot complaints about safety problems with the airline and

raised questions about oversight of airline maintenance practices, both by

government regulators and the airlines themselves.

Besides ruling on the cause, the board made 15 safety recommendations to the

Federal Aviation Administration, including provisions for revised maintenance

procedures, improved training for flight crews, the redesign of DC-8 elevator-

control tab installations, and replacement of DC-8 aluminum elevator-geared

tab crank arms.

The NTSB is an independent panel that recommends safety improvements but has

no enforcement powers.

Emery grounded its airline fleet on Aug. 13, 2001, when the FAA threatened to

revoke its license for 100 alleged safety violations unearthed in a series of

inspections dating from January 2000, a month before the crash.

Emery's parent company, CNF Inc. of Palo Alto, Calif., later disbanded the

airline in a reorganization. The FAA revoked the airline's operating

certificate in December 2002.

The NTSB's findings and recommendations mainly focused on issues with the

design of the control linkage involved in the crash and on related safety

procedures.

But John Goglia, the board member who followed the crash investigation most

closely, said afterward he thinks the crash involved safety issues that go

beyond problems specific to the aging DC-8s or the defunct Emery airline.

"It's clear that many of the elements that led to the crash of ValuJet in the

Everglades were present in this accident as well," Goglia said, referring to

the 1996 airline crash that killed 110 people.

Investigations of the ValuJet crash revealed a trend among discount passenger

airliners to contract out much of their work, including maintenance, with

little oversight from the Federal Aviation Administration.

Emery also contracted out much of the maintenance work for its airplanes, and

Goglia, a certified aircraft mechanic, was harshly critical of Emery's

maintenance management during a hearing in May 2002.

In June, a Department of Transportation Inspector General's report also

sharply criticized the FAA for lax oversight of aircraft maintenance

companies.

"Air carriers have increasingly gravitated (from company-owned facilities) to

repair stations for aircraft maintenance, yet FAA has made no similar shift

in its oversight of these facilities," it said.

At Tuesday's meeting, Goglia added two recommendations to improve maintenance

practices throughout the airline industry. One would require airlines to give

mechanics explicit directions on how to do specific maintenance tasks. The

other would require airlines to make sure repair manuals were accompanied by

up-to-date installation drawings.

Goglia was sharply critical of Emery on both counts, but at Tuesday's hearing

he also pointed out the board had urged the FAA to require more explicit

maintenance instructions after a 1996 accident.

Goglia said the board later ruled the FAA's response to the

recommendation "acceptable" when the agency issued guidance to its primary

maintenance inspectors. "Maybe we were premature. . . . At least the message didn't get down to the (FAA inspector) on Emery," Goglia said.

Family members of the victims were relieved that the board officially cleared

their names, said Fred Chesbro, Stables' brother-in-law and a military pilot

based in Hawaii. But Chesbro said he was surprised at the board's lack of recommendations on oversight issues. "The probable cause finding seemed (to have) a narrow technical focus. I don't think it means the (oversight) issues are any less present," he said.

CNF Spokeswoman Nancy Colvert said the board's action closes the case on the

accident, but she noted several civil lawsuits are pending.

[From the Dayton Daily News: 08.06.2003]