ERA12RA367A . . . collided in flight in the vicinity of Sumerduck, Virginia. . . . Under the provisions of Annex 13 to the Convention on International Civil Aviation and by mutual agreement, the United States delegated the accident investigation to the government of Canada. The NTSB designated an accredited representative to the investigation on behalf of the United States, and the FAA designated an advisor to the accredited representative.
The investigation was conducted by the Transportation Safety Board of Canada under its statutes.
A review of this investigation, delegated to a different country's "investigating authority", was presented by Jon Lee, at ISASI's Vancouver gathering in 2013:
The NTSB-staff has consistently blocked all efforts to revise AAR-81-8.
Over decades communications to the "Board Members" were diverted to staff.
Without some outside intervention,
NTSB AAR 81-8 will never be revised, nor retracted.
Though the NTSB has no effective oversight,
perhaps an appropriate Subcommittee, in USA's Congress,
might persuade NTSB Board Members toward
512 Dirksen Senate Building; Washington DC, 20510
House: Subcommittee on Aviation
2251 Rayburn House Office Building; Washington, DC 20515
(a) Establishment.-- If an accident involves a substantial question about public safety in air transportation,
the National Transportation Safety Board may establish a special board of inquiry composed of--
(1) one member of the Board acting as chairman; and
(2) 2 members representing the public, appointed by the President on notification of the establishment of the special board of inquiry.
(b) Qualifications and conflicts of interest.--The public members of a special board of inquiry must be qualified by training and experience to
participate in the inquiry and may not have a pecuniary interest in an aviation enterprise involved in the accident to be investigated.
(c) Authority.--A special board of inquiry has the same authority that the Board has under this chapter.
. . .
NTSB's AAR-81-8 = The Boeing Scenario
dated June 9th, 1981
... a predetermined plan of deception at the Inquiry
... an attempt to conceal
a series of disastrous administrative blunders
... I am forced reluctantly to say that
I had to listen to an orchestrated litany of lies
... disappearance of documents ...
1990 --- 1991 --- 1992 --- 1993 --- 1994 --- 1995
". . . Board Member ... Ehrlich said CSB’s problems have largely been due to the
‘confused and ambiguous lines of authority’
between the chairman, board members and other staff."
Testimony on March 4th, 2015: details IG-oversight of CSB,
Final Report, Commission of Inquiry into the Air Ontario Crash at Dryden, Ontario, Preface, pg xxii:
... . . . "... reinforced my strong belief in the value of a public Inquiry under the Inquiries Act.
As a means of conducting an investigation . . . such an Inquiry under
. . . . . . the Inquiries Act has the great advantages of
. . . . . .. . ..virtually unlimited power to subpoena witnesses and
. . . . . . . . . . . . . . . . . . . . . . . the testing of their evidence in the crucible of cross-examination.
I am convinced that, as an instrument in the search for truth, a public Inquiry, judiciously and fairly conducted has no peer. . . . my intention that the concept of procedural fairness would be the basic tenet of this Inquiry . . .
. . . In the course of any commission of inquiry,
. . . . . . . . allegations will be made at public hearings
. . . . . . . . . . . .which will reflect adversely on certain parties.
It is my position that any party adversely implicated
. . . . by testimony at the public hearings of the Commission
. . . . . . . . shall be given a full opportunity to be heard."
Nokia … a classic example of the perils … for industry leaders. . . .
underlines how little influence board members often have
when faced with an entrenched management team. . . .
a board’s role must be
to challenge management.
Bosses must have an attitude of “paranoid optimism”. . .
"Crossed lines in the boardroom"
The Economist , Nov 15th 2018 , Business, Bartleby,
Parallel INVESTIGATIONS, to contrast against USA's investigation of TWA841 / 4Apr79:
NZ's Commission of Inquiry, Air New Zealand DC-10 TE901 / 28Nov79
Chippendale's Report versus the Mahon Report.
"the corruption of the craft"
Revision, 24Dec2015: The old 845.41 has been REVISED, renumbered to 845.32
The revised §845.32 omitted the NTSB's "response" obligations .
This § 1112 "Special Board of Inquiry" -- in the early framework for a new NTSB --
missed the intended function of
a Public Inquiry
(a missing investigative safeguard).
To correct weaknesses,
§ 1112, §1137, §1138, §845.32 need rewrite, to explicitly include
NTSB AAR's suffer from this lack of quality-control,
this lack of investigative "safeguards".
US National Academies aims to shift thinking about scientific misconduct
away from corrupt individuals . . . toward researchers working within a flawed system . . .
The National Academies committee is considering expanding the definition of research misconduct,
and taking into account
the responsibilities of . . . institutions, . . . and professional societies. . . .
[From an AAAS session on 13 February 2015,
the National Academies' committee report is now available, released June 2015.]
This website will cease to exist
in a few days.
Why do they deserve protection from the public eye?
Research cheats are no different from other bad actors . . .
always been difficult
yet properly used are
an essential part of
the scientific record.
"Confusion often occurs about whether, and when,
it is appropriate to issue
a full or partial
expression of concern ..."
Targeting repairs to Laws for fixing NTSB's future mistakes.
Meant for Congressional subcommittees.
". . . On December 2, 1991, Trans World Airlines, Inc., filed a petition . . .
Ignoring the NTSB-bias, and erroneous findings,
the court ignored the errs, ignored misconduct,
from the Boeing-NTSB investigation:
the court lacked jurisdiction to hear the case.
The NTSB's newest "Quality of Information" upgrade is laced with contradictions:
The various contradictions [eg, NTSB's unworkable 845.41(a)],
hidden as "exceptions" to that added Quality- "mechanism"
immediately yielded that new "mechanism"
just as hopeless and as ineffective as the original "safeguard" -- 845.41(a).
. . . Canadian Aviation Safety Board (CASB) investigators were at the accident site
within hours of the Dryden crash.
However, intense public controversy raged . . .
The CASB Dryden inquiry . . . was halted by
the Minister of Transport, who opted for
a public inquiry. . . .
the Government of Canada,
facing mounting public criticism . . .
replaced the CASB with
a Commission of Inquiry under the Inquiries Act
to investigate the Dryden accident. . . .
The CASB Chief Investigator and most of his team
were seconded to the Commission . . .
Using a Commission in this way is rare and
was done to restore credibility to
the aviation accident investigative process . . .
. . . Credible investigation must be independent and dignified (without appearing elitist), transparent and without constraint. Most importantly, it must be perceived by the public as free from vested influence.
Effectiveness of the Judiciary
It can be argued that the judiciary is uniquely positioned to resolve these issues.
A Commission of Inquiry under the Inquiries Act,
unlike an investigative body such as
CASB or ... TSB
vests in Commissioners:
- - All the powers of a superior court judge;
- - Freedom and independence from
political or governmental influence . . .
Cite this case, ID, or click-copy the image below:
"under certain circumstances" correction-retraction
by "other responsible persons"
is a step to recognition-acknowledgement of such published investigator-err, and scientific misconduct.
Failure - Interactions
The model wording for
revising a future §845.32 "Petitions"
is shown in current law,
see the detailed "response" obligations listed in §1135:
Those detailed "response" obligations, as stated in §1135, could
should be seen as a badge of honour,
not something you’re embarrassed about. . . .
However that’s not always how the public perceives it, or the way it’s written up . . .
Institutions may also worry that their definitions of misconduct and … investigation
differ from those of other institutions . . . “
“I think it’s completely improbable … to say
It’s just not credible”.
Elizabeth Wager. . . member of UKRIO’s advisory board.
Nature 521, 271(21 May 2015)
Court of Appeals, Ninth Circuit
to review the NTSB's action.
Jurisdiction is a question of law ...
... no court has directly addressed the issue
the Independent Safety Board Act,
grants jurisdiction over an NTSB denial of a petition ...
court decision = courts lack jurisdiction
this court case only raised more doubts
about quality of NTSB's products.
NTSB has lacked basic foundations of
a scientific organization:
No IG - review of any NTSB-AAR.
No peer review process to identify investigator-err.
No disclosure of those protest Petitions buried by staff-managers.
Petitions are reconsidered ONLY by
NTSB's own board members & staff :
an intangible conflict-of-interest.
No acknowledgement of employee Scientific Misconduct.
No defined oversight role for Board Members.