Saturday, September 3, 2016

The disaster that taught us to fly safely: 45 years after Flight 1866



In the first week of September, 45 years ago, Robert Mottram flew by helicopter to the Chilkat Mountains west of Admiralty Island. It was not a pleasant experience.

On Sept. 4, 1971, Alaska Airlines Flight 1866, en route from Anchorage to Seattle via Cordova, Yakutat, Juneau and Sitka, slammed into a mountainside while approaching Juneau International Airport. All 111 people aboard the aircraft were killed. It was — and remains — Alaska’s worst air disaster.

“It’s like being on another planet,” wrote Mottram, the Juneau bureau chief for the Associated Press, at the time.

At 2,500 feet above sea level, the accident site was enveloped in fog and mist. Instead of a junked aircraft, Mottram saw a junkyard littered with debris and gore.

“There isn’t a piece of that 727 jet too big to hold in your hand. The only sound is the wind and the voices of the rescue workers. The clouds move in and out, and you stand on soft, spongy ground, uneasy,” he wrote.

Mottram watched as Juneau National Guardsmen and Alaska State Troopers collected the remains of the victims, pieces of people. It would take more than a week to gather those remains and almost a month more to identify them.

“You have difficulty even visualizing what it was … visualizing an airplane with smiling people aboard and the stewardess saying, ‘Good afternoon, ladies and gentlemen,’” Mottram wrote.

“It is very quiet up there.”

Today is the 45th anniversary of the accident, and if you fly by helicopter to the crash site just as Mottram did, you will still find quiet. You will still find wreckage, too. Resting on stony ground are pieces of fuselage and structure clearly marked with the orange stripes Alaska Airlines used in the 1970s.

The wreckage has remained undisturbed, but flying hasn’t. In the past 45 years, commercial aviation — both in Juneau and across the nation — has become safer. In 1970, according to statistics kept by the U.S. Department of Transportation, crashes killed 146 people on scheduled commercial flights with more than 12 passengers. These crashes took place in a year when commercial flights scheduled fewer than 2.7 billion miles.

In 2015, American commercial flights covered nearly 7.7 billion miles — with no fatalities. No large American airliner has crashed since 2009.

That safety record is at least partially a result of lessons learned 45 years ago. Flight 1866 inspired changes in prevention and response that have saved thousands of lives.

Forty-five years on, Flight 1866’s crash site is still quiet, but its impact resounds.



Barlow inbound

On the morning of Sept. 4, 1971, Flight 1866 took off from Anchorage under the command of an experienced crew headed by 41-year-old Dick Adams, a pilot with almost 14,000 hours of flying time. Adams had been with Alaska for more than 16 years and was one of the airline’s more experienced pilots.

He was joined in the cockpit by two other experienced crewmen with ample training in the Boeing 727 they flew.

In “Character and Characters,” an oral history of Alaska Airlines, author Robert Serling describes the people aboard as “a typical cross-section of passengers from every walk of life, every age group, every economic stratum.”

Most were from Alaska. There were nine freshmen heading to class at Sheldon Jackson College and four going to Mount Edgecumbe school.

The Anchorage Daily News published brief profiles of some of the others:

• Harvey Golub, Alaska’s most experienced bridge engineer, was on his way home from a meeting in Anchorage where he was planning a bridge across the Yukon River.

• Cathy Peak was married to a Coast Guardsman stationed in Cordova and was flying home to visit family in Missouri with her sister and daughter.

• Judy Nichols was taking her infant son Stephen to meet her future husband in Juneau.

• Clint Schilstra was an all-tournament basketball player for Kake at the Gold Medal tournament and taught at the town’s school.

• With Schilstra was Kake’s schools superintendent and three other teachers; all were flying home with several hundred pounds of moose meat from a successful hunt in Yakutat.

The weather on the day of the crash was typically bad — heavy clouds and fog that forced Adams and his crew to land using instruments instead of peering from their cockpit windows. Juneau’s surrounding mountains preclude the use of normal instrument approaches, but the Federal Aviation Administration has long operated a navigation aid called a “VHF omni-directional range” (VOR) beacon.

This beacon, located on Sisters Island in Icy Strait, sends out a radio beam along a set course. It’s supposed to be a reliable landmark when murky clouds interfere with navigation.

Another beam comes from the localizer, another beacon at the airport. By determining the angles of the beams reaching an aircraft, that plane’s pilot can determine the aircraft’s approximately location.

On that day, however, the Sisters Island beam wasn’t reliable — unknown to anyone, it was almost 45 degrees off its correct direction. According to the official report compiled after the crash, the beacon was sending out a correct signal, but the plane’s instruments were receiving an incorrect one.

As a result, when Flight 1866 began to descend toward Juneau, the plane’s crew thought they were eight miles east of the Chilkat Range, at Barlow Cove on Admiralty Island, not directly above the range’s peaks.

The crew had ways to verify the plane’s location, but using them wasn’t required and wasn’t part of the normal landing procedure. Also, the crew had no reason to believe they were off course.

In its report on the accident, published 13 months after the crash, the National Transportation Safety Board concluded, “the probable cause of this accident was a display of misleading navigational information … The origin or nature of the misleading navigational information could not be determined.”

There were no signs the plane ever slowed down or realized it was about to strike a mountain.

“This was a nonsurvivable accident,” the NTSB report stated.

Responding in a fog

That Sept. 4 was a Saturday, but Charlie Smith was in his office at the Alaska Department of Public Safety when word of the crash arrived. He’d spent some of the workweek in Anchorage and needed to catch up.

“It was a Saturday, and ironically, I had a ticket to come back on the same plane, but I came back a day early,” he said, sharing his memories of the accident in an interview over coffee. He still lives in Juneau.

In addition to working for the state, Smith was the National Guard lieutenant in charge of Juneau’s Guard detachment.

When learned about the accident, he began calling his superiors, asking for permission to mobilize his soldiers to help. When he couldn’t reach them — it was a holiday weekend, after all — he called them out on his own accord.

“Granted, it was a recovery, but it started out as a search and rescue mission,” he said.

The flight was due to land in Juneau shortly after noon, but when it didn’t arrive, everyone involved knew it was in trouble — they just didn’t know where. The crash wasn’t found until a hired helicopter with an Alaska State Trooper and an Alaska Airlines pilot aboard discovered it about 4:30 p.m.

Troopers arrived by helicopter that night to secure the scene and look for survivors, according to an account drafted by the coroner’s office. The Guardsmen arrived the next morning, some of them carried by the Coast Guard cutter Sweetbriar, which was based in Juneau and stayed on scene while workers recovered bodies and debris deemed critical to the accident investigation.

A base camp was established at sea level, and for almost a week, helicopters flew constant missions, flitting between base camp and the accident site, between base camp and the airport, and between base camp and the National Guard armory (today’s Juneau Arts and Culture Center), which became a morgue.

Juneau’s National Guardsmen were combat engineers, not crash recovery experts. On training missions, they built radio stations and playgrounds.

“These young folks really did one heck of a job even though they didn’t have any specific training,” Smith said. “The only training we had back in those days was riot control training because it was the late ’60s, early 70s. … We never had anything like this.”

Dennis Egan, now state senator for Juneau, was in the National Guard at the time of the crash.

“My wife and I were in Valdez when the crash happened, and lo and behold, we were activated,” he said.

They drove to Anchorage and got onto a flight that took them back to Juneau, where Egan spent the following two weeks recovering remains and working at the morgue.

“It was horrible. It was just horrible,” he said. “Guys on the plane were friends of mine. Everybody in this town, because it was small enough back then, knew somebody who was on that flight.”

Three refrigerated container vans were kept operating 24 hours a day to store the remains while the FBI laboriously identified them through fingerprints, dental records and jewelry. It wasn’t until the end of September that all the remains were identified and left Juneau, according to the coroner’s report now kept in the Alaska State Archives.

The process left the armory almost unusable, Smith recalled.

All of the FBI and forensics experts were walking around with cigars, Egan said.

When he asked why, one of the FBI men cryptically responded, “You’ll get it.”

“Opening up those cooler vans — the stench stayed in there because there was so much formaldehyde and other stuff,” Egan said.

Afterward, the armory’s floor was pulled up and replaced, and its walls were repainted to get rid of the smell.

Fixing the problems that led to the accident would not be so easy.

Repairing navigation

It became apparent even before the official report that faulty navigation — whether on the part of the pilots or the FAA — was to blame for the accident. Flight 1866’s “black box” cockpit and ground-control recordings were almost immediately recovered and it was discovered that there were no flaws with the aircraft or crew, who believed themselves well east of the mountains.

Even though the official investigation wasn’t complete until 13 months after the accident, Gov. Bill Egan wasted no time calling for better groundside navigation equipment.

On Sept. 9, five days after the accident, he wrote a letter to the Secretary of Transportation urging him to upgrade the navigation equipment on Sisters Island.

“It is my sincere hope that you will understand that because of the topography of the landscape approaching Juneau that extraordinary measures are warranted at once, simply to provide additional air safety … that most air travelers take for granted as already being a part of the system,” he wrote.

The FAA responded promptly. By year’s end, the agency installed distance-measuring equipment at Sisters Island that would have given the pilots of Flight 1866 a safeguard against the disaster and might have prevented it. The FAA also mandated new standards for planes flying into Juneau’s airport, which had to fly a steeper approach and hold to tougher weather standards.

After the NTSB report failed to come up with an adequate explanation for the bent beam, Alaska Airlines employees found the Sisters Island beacon wasn’t set up according to the FAA’s own standards, Serling wrote in his book.

Furthermore, while conducting their own experiments, the airline employees found that the beacon could send flawed signals on the rare days when Icy Strait was millpond-smooth. On those days, the beacon’s radio signals could suffer from interference and rotate the signal counter-clockwise, just as experienced by Flight 1866.

The results of the airline employees’ experiments were not be duplicated by the FAA’s own tests, and the federal agency continues to state in its own official history that “the origin or nature of the misleading navigational information could not be determined.”

An FAA spokesman declined to answer questions about the accident.

When lawsuits pertaining to the accident were settled in the mid-1970s, the FAA contributed millions of dollars to the final amount paid to the families of crash victims. The exact amount and the details of the settlement remain sealed from public view by court order.

‘Saved’ at the airport

John Ladner is Alaska Airlines’ director of operations, the man responsible for training the company’s pilots and ensuring that the experience of Flight 1866 doesn’t happen again.

“The navigation systems have evolved dramatically in the decades since 1971 when this accident happened,” Ladner said by phone from Seattle.

The distance-measuring equipment added by the FAA “gives you a more clear depiction of where you are,” Ladner explained, but it wasn’t a perfect solution, particularly in Juneau.

“Juneau is arguably one of the most difficult airports to fly into in the entire country,” said Bobbie Egan, a spokeswoman for Alaska Airlines.

That difficulty led to more accidents like the one that claimed Flight 1866. In 1985, a LearJet crashed into the Chilkat Range, killing all four people aboard. In 1992, an Air National Guard aircraft crashed into the mountains, killing all eight aboard — including a brigadier general.

Those accidents — each considered a “controlled flight into terrain” as Flight 1866 was — convinced Alaska Airlines and the City and Borough of Juneau (which owns the airport) that more improvements were needed.

The solution was a system called “Required Navigation Performance,” which combines onboard navigation and the GPS satellite network to create precise landing paths. It improves safety and efficiency and is reliable even in fog or bad weather that obscures the runway.

“I think that each of these sorts of accidents, and especially Flight 1866 … was a big driver toward making a safer way to get in there,” Ladner said.

In the 1990s, Alaska Airlines and Juneau officials — including Dennis Egan, who was the city’s deputy mayor at the time — lobbied Congress to make Alaska’s capital a testbed for RNP.

When the system began operating in 1996, it was the first of its kind in the world.

It was successful almost immediately. Alaska Airlines began keeping track of its “saves,” flights able to land under RNP that would have been stopped by bad weather otherwise.

In 2011 alone, Alaska Airlines logged 831 “saves” at Juneau International Airport, the company’s then-chairman, Bill Ayer, said at the time.

In 1998, following Juneau’s experience, the FAA certified standards that allow airlines to set up their own RNP landing approaches at airports across the country. Internationally, other countries have also set up similar programs.

“The RNP has really been something that I think has been a great addition to flying safety,” Ladner said. “It’s really been able to make it safe and efficient.”

‘Terrain! Pull up!’

In the days after Flight 1866 crashed into the Chilkat Range, a small plane deliberately traced its path west of Juneau. Aboard the plane was a young engineer named Don Bateman, and in the plane was a warning device that he had invented. As Bateman’s small plane neared the fatal mountain, a warning sounded. His plane pulled up and flew to safety.

Flight 1866 didn’t have that warning.

“I was disappointed,” Bateman told Bloomberg reporter Alan Levin earlier this year, recalling the experience of flying over the site. “We needed to do better.”

Bateman, now 84, is the inventor of the Ground Proximity Warning System, a device that warns pilots when their planes near mountains. In the 1960s and 1970s, when Flight 1866 crashed, the most common cause of airline disasters was what the National Transportation Safety Board calls “controlled flight into terrain” — hitting the ground without warning.

“This (controlled flight into terrain) is something that really over the decades the industry has tried to reduce,” Ladner said.

Since 2001, when the FAA began mandating that commercial airliners use an enhanced version of Bateman’s system, not a single commercial airliner has crashed due to a “controlled flight into terrain.”

President Barack Obama awarded Bateman the National Medal of Technology and Innovation in 2011, recognizing his achievement.

Where the RNP system pioneered by Alaska Airlines is designed to keep planes on track, the equipment designed by Bateman gives pilots critical seconds of warning if something goes wrong.

Three years after Flight 1866’s crash, the FAA began requiring large airliners to carry radar altimeters. These devices let pilots know if they were unexpectedly nearing the ground, but they didn’t give advance warning if a plane was approaching a mountain in front of it.

After the end of the Cold War, improvements in computer technology and the availability of electronic terrain maps meant that planes could carry a nearly foolproof warning device.

“A wonderful thing happened during the end of the Cold War … enlightened people on both sides decided to use the digitized terrain that was developed for military purposes for cruise missiles and so on ... for the civil sector, and that’s been very, very good,” Bateman said in a 1998 hearing about the crash of a Boeing 747 on Guam.

The newest versions of the warning system give as much as several minutes’ notice before a crash, allowing pilots to avoid problems before they become fatal. With a digital voice that shouts “Terrain! Pull up!” the warnings are impossible to miss.

“It’s accidents around the world that drive us to find a better way to do things,” Ladner said. “Smart people start making better devices so we can continue to find a way to operate safely.”

Improvements to response

Even with these technological breakthroughs. The FAA does not require ground-proximity warning systems like Bateman’s on air taxi aircraft or private aircraft, which now make up the vast majority of fatal air disasters in Alaska.

On Wednesday, a pair of small aircraft collided in midair near the Yukon River town of Russian Mission, killing all five people aboard the two planes.

As happened 45 years ago with Flight 1866, the Alaska State Troopers and Alaska National Guard were the first on the scene. The response, however, was very different, based on lessons learned in part from Flight 1866.

Lt. Col. Tony Stratton of the National Guard is in charge of the Guard’s emergency response in Alaska. In 1971, a 32-year-old Juneau lieutenant called out the Guard to help. If the same thing were to happen today, a lieutenant wouldn’t be making that call.

“Communications is probably the biggest difference from then to now,” he said by phone from Anchorage.

The state and federal agencies operate a rescue coordination center and emergency operations centers as needed to coordinate agencies and help.

“The RCC has a list of agencies that include the Air National Guard, Army National Guard, Civil Air Patrol, Alaska Mountain Rescue … it’s an extensive list, and they’ll go through that list to match needs and capabilities,” he said.

Instead of Smith and Juneau troopers calling friends and neighbors to help, there’s a set procedure and process to call into action.

There’s better training, too, said Lt. Bryan Barlow, aircraft section commander of the Alaska Department of Public Safety.

“State troopers receive specific training in search and rescue and the Incident Response System in their academy curriculum as well as continuing and advanced education in the same topics once they are working in the field,” he wrote.

That’s a marked difference from 1971, when Sgt. Harcourt Tew, an instructor at the Trooper academy, wrote in a memo, “I do not feel we were prepared, either with equipment or training, to handle a situation of this type.”

Equipment is different and improved. In 1971, the National Guard and Troopers had to turn to Juneau’s sporting goods stores for the gear they needed to work in the Chilkat Range.

Now, Troopers and Guardsmen have prepackaged disaster kits that can be delivered by helicopter or aircraft to the scene of an accident.

In August, the National Guard tested one of those kits, a 25-person “Arctic Sustainment Package” in an exercise designed to simulate a sinking cruise ship in the Bering Sea.

Both agencies say they are better-equipped to handle the human aftermath as well.

“Some of my people had some problems with it,” Charlie Smith recalled.

One man, who had served during the Vietnam War, said the scene in the Chilkat Range was worse than anything he saw on the battlefield. Overseas, he hadn’t had to cope with the body parts of friends and neighbors.

He later asked Smith for a letter of support as he sought federal disability for post-traumatic stress disorder.

“Back in those days, they probably didn’t get into drugs, but some of them got into alcohol and stuff like that,” Smith remembered.

“Back then, maybe you visited the chaplain because you were having issues or because you were concerned,” Stratton said. Now, “we have (critical stress) instructors who are specifically trained in this arena. When they come back out of the field, they’ll be received by the same group.”

A disaster, as it turns out, can affect even the uninjured.

An unforgettable album

Robert Mottram has retired from the Associated Press. Now living in Anacortes, Washington, he writes books — one about dogs, another about RV-ing across America.

During our conversation, he said he distinctly remembers a photo album found by then-state Sen. Bill Ray, who visited the crash site during the recovery.

“I stood and looked over his shoulder as he flipped through the pages,” Mottram said.

“It soon became apparent that this album belonged to a little girl, a little Native girl who was in a lot of the pictures. It was full of family shots and as we proceeded through the pages, it became apparent who the little girl was,” he said.

She was one of the students traveling to Mount Edgecumbe boarding school in Sitka from the North Slope.

Mottram said he and Ray concluded that the girl had taken the album with her because she wanted to introduce her school friends to her family, “or, she was taking it because she was going to be homesick and she wanted to bring a part of her family with her.”

Alaskans and the world have learned from Flight 1866. Aviation is demonstrably safer and more reliable.

“Absolutely,” Egan said. “I’m no pilot, but I can guarantee it.”

Mottram said he knows it too, but he also can’t help but think about the price of the lesson.

“There were young people who would be alive,” he said. “Those people are still dead, and they probably wouldn’t be yet. When you think about the kids and you think about the potential there, that’s potential we are lacking now. We should still be benefiting now.”

“Your mind absolutely refuses to compute,” Ray wrote in the Juneau Empire following the crash.

“You breath deeply — again and again — trying to compose your stunned emotions and with an intense effort you barely manage to curb the insane desire to run away — blindly — anywhere, just away. … You shudder, blink back the rapidly forming tears, and once again look downward in abject futility at the still and unmoving forms. Why, Dear Lord, why …”

Story, video and photo gallery:  http://juneauempire.com

NTSB Identification: DCA72AZ003
14 CFR Part 121 Scheduled operation of ALASKA AIRLINES INC
Aircraft: BOEING 727, registration: N2969G

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