Member John J. Goglia’s Statement

This is a maintenance accident. Alaska Airlines’ maintenance and inspection of its horizontal stabilizer activation system was poorly conceived and woefully executed. The failure was compounded by poor oversight. Lubrication periods were extended, while inspection intervals were simultaneously lengthened, neither with sound technical basis. And, if logic and standard practice dictate that as risk increases so should monitoring, Alaska’s program was otherwise....Had any of the managers, mechanics, inspectors, supervisors, or FAA overseers whose job it was to protect this mechanism done their job conscientiously, this accident cannot happen. The jackscrew is robust. Even at its wear limit condition, it is many times strong enough to carry out its function. And it does not wear quickly when cared for. It is a time-tested mainstay in the fleet, and one major carrier with a diligent approach to its maintenance has never seen one seriously wear, much less wear out. A whole herd of miscues was needed to allow it to fail. Virtually any system on an aircraft treated with the indifference shown to this mechanism will break, many with equally catastrophic effect....

Alaska Airlines expanded rapidly in the years before this accident. With the goal of becoming more profitable, as they became bigger and busier the pressures to keep their planes on schedule put increasing stress on their maintenance facilities. And this took its toll. The Federal Aviation Administration seemed to know this, but was nowhere effective in preventing the tragic chain of events. So N963AS began its fateful path in a C-check years before falling to the ocean. Its maintainers found a jackscrew that needed to be pulled, but no spare was found and, as the part was arguably acceptable, they pushed the plane back into service, with no watch list, no trailers, or orders to keep track of its condition. There were no specific procedures to do so, and no one thought enough to ask for one. The aircraft was arguably, that is technically, legal, and it was probably safe, if it was carefully greased. It was not, we know that without question. And the lengthened inspection intervals were such that it was not to be looked at again, until it was in our laboratory. When it finally failed, ground support from Alaska Airlines seemed to encourage the crew to proceed with a broken plane on to their scheduled destination, for reasons perhaps of convenience both to passengers and maintenance – we won’t really ever know. But the impression is inescapable. An aircraft that had been hustled out the door three years earlier for the convenience of scheduling was now encouraged to keep to its appointed routing. It is less coincidence than culture....

Like the old adage says, “you schedule maintenance, or the maintenance will schedule you.”