The woman in 14A was settled into her window seat, buckled in for the flight home. Moments later, with a sudden burst of violence at 32,000 feet, the window was gone.
Fan blade No. 13 had broken off inside the left engine, hurling shrapnel against the side of the plane. Her window disappeared out over the eastern Pennsylvania countryside, and Jennifer Riordan's upper body was sucked halfway through the opening left behind.
During the 17 wrenching minutes that followed on that April morning last year, pilots struggled to guide the hobbled plane to an emergency landing and passengers fought to save the mother of two from Albuquerque, New Mexico, leaving a legacy of heroism in an incident that travelers around the world may have taken as a nightmarish, if seemingly random, accident.
In fact, federal regulators and the companies that built and flew Riordan's plane knew from experience that such a scenario was possible. Nineteen months earlier, in August 2016, a fan blade had broken off in the same model engine on the same model Southwest plane over Mississippi.
The engine blowout damaged the plane in that case as well, but the passenger cabin "was not penetrated," investigators said. The pilot was able to make an emergency landing and no one was hurt.
The Federal Aviation Administration began crafting a proposal for more inspections after the first engine failure. But it did not order those inspections until after the failure repeated itself on Riordan's flight.
The FAA's halting response troubled some inside the agency who say it fit a pattern of giving too much deference to industry - including airplane manufacturers and their suppliers, airlines and others. The issue has taken on added urgency following the crashes of two Boeing 737 Max jets in Indonesia and Ethiopia that killed 346 people.
In a statement, the FAA said it "promotes a strong safety culture across the industry" and had acted in "an expedient manner" following the initial Southwest incident.
"The actions taken by the FAA were consistent with our established and proven risk-based processes," the agency said.
The National Transportation Safety Board last month raised concerns about the design of the Boeing Next-Generation 737 planes at issue in the Southwest incidents, noting that the broken fan blade on Riordan's flight destroyed part of a structure that houses the engine known as a fan cowl. A metal latching mechanism that was part of that structure flew out and smashed against the plane, causing Riordan's window "to depart," the NTSB said.
As FAA officials have sought to offer reassurances about the rigor of agency oversight in the months since the 737 Max crashes, they have repeatedly said that over the past decade U.S. airlines have carried 7 billion passengers around the country with just one fatality.
Riordan was that one in 7 billion.
* * *
Jennifer Riordan was 10 minutes late to her own wedding, something her husband, Michael, still jokes about.
But there was no way she was going to be waylaid at New York's LaGuardia Airport after a business trip. She wanted to be back with her family.
As Riordan, 43, nestled in for the ride, two recent medical school grads sitting in the next row prepared to return home from their New York honeymoon. A pair of Texas grandparents settled in after their first visit to Manhattan.
This account is based on a review of hundreds of pages of documents from the crash investigation, NTSB interviews with pilots and passengers, U.S. and European regulatory filings, interviews with regulators and people close to Riordan, and a video stream of her memorial.
As the Boeing Next-Generation 737 climbed out of Queens before 11 a.m., a request went out from the cockpit to the flight attendants in the back: "Whenever you guys are both up here, would you just give me a ring and just throw me some peanuts?"
First officer Darren Ellisor guided the plane toward cruising altitude, headed for Dallas and Riordan's connecting flight.
Then, at 11:03 a.m., a cascade of sound, vibration and terror.
Andrew Needum, a firefighter from Celina, Texas, heard a pop, then screams. William Crowley, a Southwest employee hitching a ride in a jump seat, heard what sounded like a marble crashing into glass, then a din so loud people struggled to hear each other. After what sounded like an explosion, school nurse Peggy Phillips watched a flight attendant nearly get knocked down as the plane shuddered.
Outside, the plane's mangled left engine had been destroyed from within. The sheared-off fan blade No. 13 had sent metal pieces from the engine's outer casing flying, gouging holes in the front of the plane's wing in addition to blowing out Riordan's window.
It felt like the plane had been "T-boned by a Mack truck," one of the pilots would recall later, and the plane rolled hard to the left.
In the cockpit, an altitude warning horn blared through the noise, signaling to the pilots that there had been a sudden loss of pressure. They grabbed oxygen masks.
The first officer gave the controls to captain Tammie Jo Shults, a former Navy fighter pilot. They radioed air traffic control that they needed to make an emergency landing.
On the ground, some authorities didn't know if the plane had been hit by a bird, a terrorist or a mechanical malfunction.
"Ladies and gentlemen, this is your captain. We're . . . going into, ah, to Philadelphia . . . ah, remain seated. Thank you," Shults said.
* * *
Nineteen months earlier, another broken fan blade sent metal fragments flying, ripping a 5-by-16-inch hole above the left wing of an Orlando-bound Southwest 737.
FAA officials began investigating. But they decided not to issue an urgent safety order, known as an emergency airworthiness directive, that would immediately require new inspections.
Citing information from the engine's manufacturer, FAA officials said the engine had been used around the world for nearly 300 million hours over more than two decades with no other fan blade breaking off. They considered the incident an anomaly and concluded that the blades fit in a "low risk" category, according to an FAA account provided to NTSB investigators.
The engine had been built by one of Boeing's suppliers, CFM International, a joint venture between General Electric and French aerospace firm Safran Aircraft Engines.
The FAA would continue to track efforts by CFM and monitor some inspections started by Southwest, officials said. That information would help the FAA craft a package of new inspection requirements using a formal regulatory process that includes time to consider comments from industry and others, the agency said. A year after the Mississippi fan blade incident, the FAA issued a Notice of Proposed Rulemaking for possible new inspections.
"It appeared that we had time to react and take actions accordingly," Christopher Spinney, of the FAA's engine certification office, told NTSB investigators.
But they did not have time, and that fit a broader FAA pattern, investigators say.
In an interview, NTSB Chairman Robert Sumwalt said investigators at the independent safety agency did not find that the FAA acted too slowly, "under the circumstances." The Mississippi engine failure "was considered a one-off event," he said.
Still, Sumwalt said, "speed" is "not the word I would use" to describe how the FAA addresses some safety issues.
"I would use 'the lack of speed,' or 'the lack of timeliness,' " Sumwalt said. "We do know that sometimes the rulemaking process, as well as other things, move slower than we're comfortable with."
The FAA's approach to the two Southwest fan blade failures was a "canary in the coal mine," said an FAA official, speaking on the condition of anonymity to talk candidly about the agency's internal operations. Those cases foreshadowed later revelations about the FAA's decision to certify that the Boeing 737 Max was safe, he said.
A flawed flight-control feature on the Max would end up contributing to two deadly crashes of the jets within five months. Some family members of those killed say the FAA did not do enough after the first Max crash.
"They knew," said Nadia Milleron, whose daughter Samya Stumo was killed on the later flight in Ethiopia. "They could have done something."
"It's another example of an FAA system that seems to be more focused on industry and industry's needs rather than safety," the FAA official said.
In a statement, the FAA said, "It is a mischaracterization to assert that industry's needs are in some way contrary to aviation safety."
Following the initial engine emergency in Mississippi, the agency said, it had worked with CFM, airlines and European regulators "to mitigate the risk of future failures in an expedient manner, including collecting and analyzing data from inspections, while developing actions to ensure safety."
Airlines initially found two more cracked blades that had the same part number as the one in Mississippi, the FAA said. That led to an early focus on the inspection of blades with that number, according to the agency.
But the failed fan blade No. 13 on Riordan's plane had a different number.
Work on the FAA's proposed inspection rules bogged down for months over just what the requirements should be, according to the FAA official who spoke on the condition of anonymity.
"Because of the comments that came in from the airlines . . . there was a lot of hand-wringing going on," the official said.
In its statement, the FAA said its actions could have far-reaching consequences, noting that they would affect "more than 6,750 aircraft, 14,400 engines and 220 operators."
The time it takes to issue safety orders "depends on the complexity of the issue, the number and type of comments we receive, how long it takes to respond to the comments and whether we make changes," the agency said.
The European Union Aviation Safety Agency issued its fan-blade inspection mandates, effective April 2, 2018.
Fifteen days later, when panic came to Jennifer Riordan's row on Southwest Flight 1380, the FAA still had not finalized its own inspection order.
Southwest said in a statement that the timing of FAA action "had no impact on the event."
"In the absence of a final ruling from the FAA, we adopted our current method of checking all blades on every engine. We began this program in 2017," and those inspections exceeded CFM's recommendations, Southwest said.
But a key question was whether industry and regulators were doing enough to ensure that hidden cracks would be discovered.
At the time of the Mississippi engine failure, field inspections of fan blades were based on a "visual inspection," according to the NTSB. But a metal coating on the blades sometimes "masked" cracks, the investigators said.
Southwest's inspectors visually examined blade No. 13 on Riordan's plane on June 21, 2017, the company said in a statement. "However, not all cracks are detectable by visual inspections," it said. The NTSB said the crack was "most likely not detectable" visually.
Within 90 days of the Mississippi incident, CFM said, it put in place a kind of magnetic inspection for some blades, which was very precise. Then, nearly seven months after the incident, the company issued a "service bulletin" calling on airlines to use a newly developed ultrasonic inspection that could essentially see cracks despite the coating.
"The team responded very quickly," Mark Habedank, a senior CFM engineer, told investigators. "We put all resources on the issue."
Southwest said it launched a program in December 2017 to inspect all its blades with the ultrasonic tool within 18 months. It was "in the process" of that when Riordan was killed, the company said.
"Blade 13 was current with all the applicable inspection requirements," Southwest said.
* * *
When the oxygen masks dropped, Andrew Needum fumbled around before getting a solid seal.
The plane shook, veered left and dropped. Needum stood up to help a young mother with an infant nearby when her oxygen tube shook loose, then buckled himself back into seat 8D. Once his own parents, son and daughter were settled as much as possible, his focus shifted to the continuous roar behind him, in row 14, he told investigators. The newly trained EMT made eye contact with his wife, seeking her approval, then headed back to try to help.
Flight attendants were struggling to save Riordan.
The newlywed doctors, Tyler and Alexis Albin, were sitting across the aisle, one row away from Riordan, and "watched in horror as her contorted body . . . was trapped with her head, arm and partial torso outside the aircraft, where the temperature was minus 50 degrees, the air speed was 500 MPH, and she suffered from instant decompression," their lawyer wrote.
They told each other "I love you," and expected to die.
Flight attendant Seanique Mallory had been trying to calm passengers gasping for air, telling them to trust their oxygen supply, when she saw Riordan, she told investigators. She jumped over the two passengers sitting beside Riordan, still being held by her seat belt, and tried to pull her back inside the plane. Fellow flight attendant Rachel Fernheimer held on to Mallory, trying to anchor her, as she kept attempting, unsuccessfully, to bring Riordan back inside the cabin.
Passenger Tim McGinty reached from row 15, out the open window and into a "tremendous" wind. "I couldn't hold my arm straight out there. It pushed my arm back around to where she was," McGinty said.
Needum reached over the passengers sitting in row 14, pulling on Riordan, but he couldn't budge her from that awkward angle. He got the other passengers to unbuckle and clear out, and reached outside, with him and McGinty throwing their full weight into the gruesome and heartbreaking tug of war.
They finally got Riordan's right arm inside, then her head, Needum told investigators. He braced his arm over the window hole to keep her inside with them, then they laid her down on the empty seats.
* * *
In the cockpit, captain Shults was trying to right the plane, which was dragging through the morning sky missing much of its inlet, a key aerodynamic structure around the engine that had shorn off over Pennsylvania just as it had over Mississippi in 2016.
After that earlier fan blade incident, the FAA considered the risks connected with the inlet.
"FAA Safety Decision - No airplane safety issue" was its conclusion, according to an agency document.
The captain and first officer, flying on a single engine, told air traffic control to be ready with firefighters on the ground.
"Yes could, ah, you tell 'em roll the trucks. It's on the, ah, engine number one - captain's side," one of them said.
Controllers wanted to know how much fuel they were dealing with. And they wanted to be certain about how many lives were in the balance.
"Southwest thirteen eighty, we're one hundred and forty-nine souls on board," Shults said.
The pilots' plan had been to take some extra time before making their final approach, to go through emergency checklists before attempting their landing at Philadelphia International.
But a flight attendant called up to the cockpit from the rear kitchen area to tell them about Riordan.
"We have people have been helpin' her get in. I don't know what her condition is. But the window is completely out," she said.
"Okay we're gonna slow down," came word from the cockpit.
Back in the cabin, Phillips, the school nurse, joined other passengers in trying to resuscitate Riordan, performing chest compressions as a doctor used a mask for the breathing portion of CPR.
Needum believed Riordan's "injuries were incompatible with life," he told investigators. But, other than for a brief pause, the passengers continued their urgent efforts for the rest of the flight.
"Are we almost there?" the flight attendant asked the pilots.
"Yes we're gonna land as soon as we can," one responded.
The pilots eyed the horizon, and tried to gauge how their wounded 737 would perform.
"I don't know the controllability of this thing," one of them said.
"Everybody breathe. We are almost there," a flight attendant told the passengers over the intercom.
* * *
Days after Flight 1380 landed safely, and the Philadelphia medical examiner reported that Riordan died of blunt-force trauma, the FAA issued an emergency inspection order.
If the "unsafe condition" with the engines is not addressed, it could lead to an "uncontained release of debris, damage to the airplane, and possible airplane decompression," the FAA said. It has issued several additional orders tightening requirements further.
In September 2018, the FAA formally withdrew its original, long-stalled inspection proposal.
"The FAA determined that the identified unsafe condition was not adequately addressed by the actions proposed," the agency said in a regulatory filing.
In a statement last month, the FAA said the information from CFM it had relied on to write its original, August 2017 inspection proposal did not cover the blades on Riordan's plane.
The FAA was preparing a new, "comprehensive" inspection mandate that would cover all fan blades "when the SWA 1380 accident occurred," the statement said.
Boeing said in a statement that "enhancements are being introduced" into the fan cowl design and to another component "to enhance their ability to withstand" a broken fan blade. The enhancements "would fully address the safety recommendation from the NTSB. Once approved by the FAA, that design change will be implemented in the existing [Next- Generation 737] fleet," Boeing said.
* * *
Michael Riordan has been so focused on what's left of his family that he has purposely avoided details on how government and industry responded after the first engine failure.
"I'm aware of the previous accident, but I'm not ready to try to understand it yet," he said in an interview.
His attention, instead, remains on Averie, 14, and Josh, 11, and trying to live up to his shared project with Jennifer to raise "amazing young adults."
"I work every moment of the day to ensure I do that for her," he said. That has meant listening to them, trying to learn what they need to live through the grief.
They have done the same for him.
Two weeks after Jennifer's death, the patio furniture the couple ordered finally arrived. Michael thought no one saw him crying as he tried to put the pieces together. Josh appeared and hugged him.
"Mom wants you to finish the furniture," his son said.
On another day, Michael broke down as he cleaned the pool. "I just kind of let it out that I can't be mom and dad," he said.
Averie took him by the face. "I just need you to be my dad," she said.
When Jennifer was a girl, she was the one who would reach out, introducing classmates to each other starting in nursery school, friends and family recalled at her Albuquerque memorial service last year. She grew into the woman who was the architect of Wells Fargo's philanthropic giving in Albuquerque.
Jennifer, the granddaughter of a gunner on a World War II bomber, would take spiritual walks at 6 a.m., working through ways to live a life of impact. Then she would stay late at parties to wash the last wineglass long after dancing her way through patented pop-and-lock moves.
"Shut the front door! I love you!" went a favorite G-rated Jen-ism. "Kind, loving, caring and sharing" was her family mantra.
Her community service centered on women's empowerment, financial literacy, early-childhood education and her city's vitality.
Her closest friends described her as "the type of woman who would fix the crown on your head without you even knowing she did so," Michael Riordan said. "She was always propping people up."
And she was always lifting people up with her snorting laugh.
Even after decades together, "I still can't explain how pure her heart was, and her drive for humanity," Michael said. "It was just Jennifer. It was an amazing spirit."
On Jennifer's birthday this year, Nov. 11, the texts and calls kept coming in to Michael, adding to his sense that people are continuing to find inspiration in her life, something he hopes to amplify through a foundation he created in her name.
"Everyone's been trying to do something in their lives that replaces a little bit of Jennifer," he said.
His buddy's wife was inspired to start delivering Meals on Wheels. A boy in Alabama sent in a $2 donation. The Albuquerque Isotopes minor league baseball team named its community service award after her.
Averie and Josh and their friends formed a youth panel to help choose grant recipients for some donations made in their mom's memory. This summer, the family joined a local artist and students to help finish the first of four city murals inspired by Jennifer. The boundless vines, roots and butterflies of the purple-and-orange "In the Garden of Sharing" now cover the wall of the Albuquerque Community Foundation.
Next year, the Jennifer Riordan Foundation is planning a nationwide tour to recognize acts of kindness, stopping in some of the towns Michael and Jennifer visited in 1994 when they drove from Vermont to New Mexico to start their life together out west.
At her memorial service, Albuquerque poet Hakim Bellamy read the words he had written for Averie and Josh, who watched, along with their dad, from behind a radiant photograph of Jennifer.
"Her currency was compassion.
"The kind of kindness that folds
"Like a hug, like a laugh, like her wings
"Before she was so close to heaven
"That the angels recognized her
"And plucked her from the sky"
As the service was ending, Josh reached up to the microphone. "She's an amazing mom," he said.