Failure - Interactions

Party-System Unreliable

NTSB:    We   must  rely on ...         

 the  Party  System.​  

Jim Hall: NTSB relies on the Party System

Even before the  

             UA585 accident  at  COS,

Harold  Marthinsen  

       had  provided  investigators

             with  Yorke's  Paradigm:


The   Prerequisite    Insight

In contrast,   during the long NTSB-investigation of
. . .   B727  N840TW  4Apr79,    

a  now   "independent" Safety Board    

was unable to  declutter,  a mass of   'data'

presented   by only one party,   ​the manufacturer.       

“My head whirls … Your words have dazed me.”

“The principal difficulty in your case,”    remarked Holmes,   in his didactic fashion,

   “lay in the fact of there being too much evidence.

 What was vital   was overlaid  and hidden    by what was irrelevant.

Of all the facts which were presented to us

we had to pick just those which we deemed to be essential,

and then piece them together in their order,

so as to reconstruct this very remarkable chain of events.”
“The Naval Treaty”:  first published in 
The Strand Magazine,   October and November 1893;
Harper’s Weekly,    October 14 and October 21,  1893.
Memoirs of Sherlock Holmes,  pg 236,     By Sir Arthur Conan Doyle

§831.8   Investigator-in-charge.

​ The designated investigator-in-charge (IIC) organizes, conducts, controls, and manages the field phase of the investigation, regardless of whether a Board Member is also on-scene at the accident or incident site.     (The role of the Board member at the scene of an accident investigation is as the official spokesperson for the Safety Board.)        The IIC has the responsibility and authority to supervise and coordinate all resources and activities of all personnel, both Board and non-Board, involved in the on-site investigation. The IIC continues to have considerable organizational and management responsibilities throughout later phases of the investigation, up to and including Board consideration and adoption of a report or brief of probable cause(s).


Paradigm

   acquisition,     awareness,     articulation,

       competition,     assimilation,     revision, 

           Anomaly,     breakdown,      _CRISIS_,    response,

               emergence-shift,    resistance,    assimilation,

                   gestalt-switch,    a  new  "view". 


The investigator's     View Through A Paradigm:  


 "...something like a paradigm is prerequisite to perception itself.  What a man sees  depends both upon what he looks at  and  also upon what his previous visual-conceptual experience has taught him to see.    In the absence of such training there can only be,  in William James's phrase,

      "a  bloomin'  buzzin'  confusion".

                     [Kuhn's Structure, pg 116.]



     Yaw  x  Roll  =  Dive!


           "Unload for control" :

                                  decouple  alpha from beta.



Without the "anticipation"  provided by this paradigm,  derived from events with "discrepant Rudder",   those key observations -- discoveries --  during the  1990's  B-737 investigations,  would never have been recognized:


 1990's Rudder Pedal events of

 -- Captain  Mack Moore's observation at ORD on 16July92 (AAR-01/01 pg69),  and

 --  Boeing test pilot   Jim McRoberts' discovery    of  Tuesday 29Oct96 at BFI.


The earlier crisis generated by the USA's NTSB AAR-81-8, in 1981,
. . . led to the long PROCESS of
. . , , , , , , , , , , , .conjecture & refutation
. . . . . . . . . . . . . . . (Popper and later Kuhn).

Inside the more "scientific" community of aerospace engineers (among experts known as S&C specialists), during the 1980's, such a PROCESS of revolution began with the powerful insight (Kuhn's "paradigm") offered by the more experienced community that had been excluded from
. . . the NTSB's system of investigation:
. . . . . . . . their closed "one-party system" observed
. . . . . . . .. . . . . . . . during the TWA841- investigation.

Their "Paradigm" had been learnt after the
......upset-breakup of Boeing 307 on March 18, 1939, and relearnt after
.......... the upset-impact of B-707 AA-Flight-One on March 1, 1962.
These are part of the paradigms passed down to today's "investigators": specifically handed down by Duane Yorke (former Grumman Director of Supersonic Aircraft Development), and from Bill Cook (Boeing) who recited the lessons from Eddie Allen and George Schairer. These paradigms, or "models", are both perquisite and prerequisite for an accident-investigator working a "mysterious" inflight upset:
By the early 1960's,     our craft  “accident investigation”,  had progressed to the stage where it was essential for the investigator to learn  from earlier techniques,  to thus provide him the required new paradigms, to fill-the-gap in the investigator's capabilities; helping him identify the new failure-interactions that eventually presented as   a  new "mysterious",   unexplained,   airliner upset, LoC-I , Loss-of-Control. 

There proved   a limit to   the  heap of  information which an untrained   "investigator"   (one lacking Kuhn's "anticipation")   could assimilate.  The hard-learnt  mishap-paradigms,  learnt from incidents and accidents of the late '50's and early '60's,  provided the investigator the template to integrate information  gleaned from the   "bloomin' buzzin' confusion":
. . . . the  post-accident  onslaught  of "evidence",
. . . . . . . . analysis,  "simulation",   "flight test"   data --
. . . . . . . . . . . . . from every direction (by various "parties").    

 In the case of George Van Epps'  investigation,
  of  AA-Flight-One / 1Mar62,
 investigators were  forcefully confronted with  masses  of data,
​ simulation and flight test data from
--  the airline,
-- the certification agency, and
-- the manufacturer,
 "data" from test-conditions (hidden-assumptions) which   Van Epps'  could not accept as representative of interactions  overtaxing those mishap-pilots.    

 prerequisite

     | prēˈrekwəzət |,

       noun :    a thing that is required as a prior condition for something else to happen or exist.

       adjective :    required as a prior condition : the student must have the prerequisite skills.


perquisite    | ˈpərkwəzit |,  

 . . . (2) • historical: a thing that has served its primary use 
​   and is then   given to a subordinate or employee as a customary right.

. . . Sometimes a normal problem,  one that ought to be solvable by known rules

and procedures, resists the reiterated onslaught of the ablest members of the group within whose competence it falls. . . .   revealing an anomaly that cannot,  despite repeated effort,   be aligned with professional expectation. . . .   normal science  repeatedly goes astray. . . .   the profession can no longer evade anomalies that subvert the existing tradition of scientific practice -- then begin the extraordinary investigations that lead the profession at last to a new set of commitments,  a new basis for the practice of science. . . .    scientific revolutions. . . . the tradition-shattering complements to the tradition-bound activity of  normal science. . . . 
                                                 [Kuhn's  "Structure", Ch1, pg5-6.] 

.

... Normal accident investigation,  the activity in which most investigators inevitably spend almost all their time,  is predicated on the assumption that the investigation-community (eg, NTSB and the parties)   has mastered   the various interactions & err-lessons available  from accident-investigation.  Much of the success of any investigation  derives from the community's willingness to defend that assumption.   


Accident investigators  often suppress  fundamental novelties (rumors, gossip, conspiracy theories,  crazy scenarios)     because such "novelties"  are subversive of the investigators' basic commitments.   Nevertheless,  so long as the investigators' commitments retain  an element of the arbitrary   the very nature of normal accident investigation  usually ensures that  any legitimate or possible  "novelty" shall not be suppressed for very long. . . .

    [OR perhaps translated better as  ...  the very nature of normal accident investigation  sometimes conceals   even a legitimate or possible  "novelty",  a scenario that might be suppressed for the duration of the official investigation.]

[ an interpretation or translation  -- from Kuhn's language  of "science" as it applies to the community of accident-investigation.]

 ​For   the  INVESTIGATOR:    

 . . . . . Contrast  two  investigations   described here.


First is the model,  or main PARADIGM:  

 . . . . . . . . .   the C.A.B.'s   George Van Epps'  case of AA-Flight-One.

 . . . . .  . . . . . . .. . . .  .. . 

Then contrast that INVESTIGATION   against the later investigation by 

the   "independent"   Safety Board,  NTSB's   "Dean" Kampschror

working the mysterious inflight upset  of a B-727 / 4Apr79,   N840TW.


Both    Van Epps     (C.A.B. during his 1962-3 case),        and

         Kampschror    (NTSB during his 1979-81 investigation)

were experienced Investigators.  Both men had served recently on other investigations,  and both men could be deemed  "over-worked".     Both served as the lead investigator,  now called Investigator-in-Charge,    or shortened to   "Eye-Eye-See",   usually written as "IIC".  


Here's the I-I-C's  job description:    

B707, N7506A, upset investigation AA Flight-One /  1Mar62

UA-pilot discovered his Rudder Pedal was binding-- restricted pedal motion.

B707 upsets

Training and various line upsets,  and

AA Flight-One

B-727,  N840TW, TWA841/ 4Apr79

Yaw x Roll = Dive,  

a  subtle 1-G "slicing-to-vertical"

B307 Stratoliner 

Flight test, upset-breakup, 18Mar1939.

In the website

"The key is to erect a genuine account of

             learning  from  error-- . . .

If anomalies are approached with white gloves,  it is little wonder that they seem to tell us only that there is an error somewhere and  . . .  are silent about its source.   We have to become  shrewd  inquisitors  of errors,   interact with them . . .  amplify them: 

             we have to learn to make them talk.  

A genuine account of   learning  from  error . . .

explaining   the growth of   scientific knowledge."

       Deborah G. Mayo

               Error and the Growth of Experimental Knowledge