The Complicated Accident Investigation
The Boeing 737 departed Chicago O’Hare’s International
Airport with a stop at Pittsburgh International Airport and a final destination
of West Palm Beach, Florida. The aircraft crashed while on approach to
Pittsburgh, in Hopewell Township, Beaver County Pennsylvania. Due to the
severity of the crash impact, the bodies of the passengers and crew were
severely fragmented, leading investigators to declare the site a bio-hazard,
requiring 2,000 body bags for 6,000 recovered remains. The conditions of the
crash site resulted in another first for the NTSB. The crash of USAir Flight
427 marked the first time in NTSB history where investigators were required to
wear full-body bio-hazard suits while inspecting the accident site.
The NTSB released its final report
on March 24, 1999, slightly more than four and a half years after the accident. The aircraft's rudder malfunctioned
and went hard-over in the direction opposite to that commanded by the
pilots. This malfunction caused the
plane to enter an aerodynamic stall from which the pilots were unable to
recover.
While not all officials agreed with
the Board’s findings as to the probable cause of the crash, several changes
resulted from them—and history bears out the success of the changes. A major
one required that Boeing redesign the rudder for all iterations of the 737. A
second resulted in a requirement that pilots receive specialized training on
how to fly the aircraft out of a stall like the one the pilots of USAir Flight
427 encountered. And a main recommendation by the NTSB required airlines to add
four additional channels of information into the flight data recorders—pilot
rudder pedal commands. [1]
Complicated Grief
Fragmentation of the bodies of the passengers and crew made
positive identification more than challenging. In 1994, DNA was not universally
used in the identification of remains of those who died in such devastating
tragedies. To help identify her son, Merrilee was able to send the medical
examiner Chad's footprints, taken from his baby book. The prints were matched to his adult foot. As
sad as this task was for Merrilee, it meant that she knew for sure that her
beloved eldest son was indeed on the flight and died in the crash. With the help of USAir's special assistance
team, Merrilee and her family were able to gather with his wife and other
family members, hold funeral services, and begin adjusting to a life where her
son was no longer physically present. The lengthy investigation and mystery surrounding the cause of the crash made further adjustment
to his loss much more complicated than it might have been under different circumstances.
The emotional pain of
the loss increases when one’s reactions are considered pathological.
The problem
for many survivors of aviation and other technological accidents where the
cause of death is not immediately known involves reactions from others. Well-meaning
people in the survivor’s social circle innocently ask questions such as, 'when are you going to
be yourself again?’ or 'how long do you plan to grieve?’. Those who make these
remarks are often influenced by what many professionals consider the normal time for grief and mourning. This lack of understanding by family and
friends, despite their good intentions, is not helped by what medical/clinical
providers view as normal and abnormal, i.e., Pathological Grief Disorder. Looking at definitions of prolonged
grief disorder from two major international resources provides insight into how
family survivors of USAir 427 experienced additional suffering due to a lack of understanding by others.
In the Diagnostic and Statistical Manual of Mental
Disorders (DSM-5), a resource that U.S. health care providers use to diagnose
mental health issues, the condition of prolonged grief is known as persistent complex bereavement disorder
(PCBD). The DSM-5 defines PCBD as severe
and persistent grief and mourning
reaction that is experienced for at least 12 months post-loss for
diagnosis. The World Health Organization
(WHO) uses even shorter time criteria (six months) for what they refer to as prolonged grief disorder. The
International Classification of Diseases (ICD-11, WHO’s diagnostic tool) defines
prolonged grief disorder as "persistent and persuasive grief response.
This grief is characterized by a longing
for the deceased or persistent preoccupation with the deceased accompanied by intense
emotional pain." That family members were preoccupied with the crash and how their loved one died, to most would seem normal. For Merrilee and many other survivors in the Foundation’s research, their intense grief lasted far longer than 6 to 12 months. Yet to those who understood their circumstances, their long grief cycle did not seem abnormal.
What Helped Merrilee as She Awaited Findings of the Probable
Cause of the Accident
During the long investigative process, communicating with
other survivors and attending annual memorial services where she could meet and
support other families of USAir 427 gave Merrilee something to look forward to
and plan for each year. Also, attending support group meetings and getting to know
families from other crashes helped. Following the crash of ValuJet Flight 592,
May 11, 1996, where 110 lives were lost, a group of family members began
meeting monthly in Atlanta, Georgia. Since Merrilee lived in Atlanta, this
gathering was convenient and proved to be very therapeutic for her.
Merrilee valued meeting other mothers,
fathers, siblings, and all who came together to share and receive support. She
also joined a local Toastmaster’s organization where she could practice
speaking about her grief experience in the presence of others. Merrilee frequently spoke at airline
family assistance team member training sessions and Family Assistance
Foundation workshops and seminars. Merrilee also journaled regularly—a coping
strategy highly recommended by trauma therapists.
In Handbook for Human Services
Response[2], I wrote a great deal about Merrilee’s story, including her profoundly moving
poem about the site of the crash. Merrilee shared the letter she wrote to the
airline about the compassionate services she received from the call center
representative that assisted her and other family members in the post-crash
activities. During the time that Merrilee waited to learn about the cause of
the accident that took her son’s life, her love for others and deep
faith in God carried her.
In correspondence this past summer,
I reminded Merrilee about a quote from her that I plan to use in a book I am
currently writing. Merrilee shared with me that in her third year of her grief, she made a
decision—she decided to devote her life
to those she loved that are still on earth. In her response, she acknowledged
her original comments and followed with another story. This example further
illustrates the challenge she and other family members continually face in
their long-term recovery. The commitment to live in the present vs. living in
the past, especially for parents who lose a child, never ends as this quote
from her email illustrates.
I want to go to Pittsburgh on the 25th anniversary of the crash in September. I want to visit the monument and the crash site. On the other hand, I have two great-grandsons in Minnesota I would love to hold, read stories to, color with, and get to know. I wish I could do both, but again, I choose the living.
Donna and Families Survivors of United Airlines Flight
585
In writing about long and complicated mourning, related to the mystery surrounding the cause of an accident, UAL Flight 585 must be included. The June 2019 issue of QPR Quick Quotes featured
an article about depression and family survivor, Donna Lucero. Her daughter,
Anita was the senior flight attendant in the crash of UAL Flight 585, March 3,
1991, where all twenty-five passengers and crew died. While the NTSB was unable
to determine the cause of UAL Flight 585 at the time, the investigation was
re-opened in parallel with the investigation of USAir Flight 427. The cause of
UAL Flight 585, was later also attributed to the malfunction of the rudder
system.
I met Donna in the ninth year of her
grief. This meeting occurred after the findings of the UAL Flight 585 were published.
Donna stated that only when the probable cause was identified, was she able to
move forward with her life. Before that time, with no answers about what had
caused the crash, no changes were being made to prevent future accidents. Donna
felt there was an absence of meaning in her daughter’s death. Donna felt stuck in her grieving process. Once the mystery of the accident was solved, the B-737’s rudder system redesigned, and the older 737's were
retrofitted with the necessary repairs, Donna’s pro-longed grief process ended.
Her life took an entirely new and healthy direction.
Before that time, she, like Merrilee and many others, was considered to be a victim of
abnormal grief. However, those who understood the suffering surrounding the
crash that killed her daughter, realized how these circumstances complicated her recovery
process.
[1]
Details of the investigation are from
the NTSB Accident Report
(https://www.ntsb.gov/investigations/AccidentReports/Reports/AAR9901.pdf
[2]
Coarsey, C.V., Handbook for Human Services Response, 2004.
