Failure - Interactions

Rohlfing  was  incredulous….

Ron Schleede]      ... whose job it was to

     make sure   that accident   investigations

                     were     competent    and     fair

         was    ready to discard …  years of hard work

                          without looking at it….    

from   Captain  John  Rohlfing's   recollections,  

          of    NTSB-staff's  response,

 to the initial "alpa"  Petition for Reconsideration,

       detailing   Yorke's refutation of   The Boeing Scenario .

              [Corsetti,   Scapegoat,    pg.   318, 335,  336.]


Inside NTSB,   


      Procedural  Non Compliance:

          After years  of  delay -- 

violating  their  Rules of Practice  §845.41(b),

                                  ignoring  NTSB's  MIM 4.15  --    

In  early 1995,   facing  that  court challenge,

    legal (court)    petition  for   Mandamus    dated January 13th, 1995,

         NTSB   staff-managers  finally responded  only

                           to  the  Attorneys'  ntsb- petition [2May1991].

NTSB  staff-managers conveniently  ignored   the more detailed  "alpa"  Petition,  
            acknowledged by NTSB as
                                    "received"   in   October 1990.

NTSB   staff- managers   erroneously  told the court  that  the two

       other  petitions-cited    would  be     

 "handled  independent  of                                          
               the subject  petition from Captain Gibson. . . ."

NTSB  staff-managers have  NEVER  acknowledged their  errs  in   AAR-81-8 :

no errata-sheets,    no revision,    NO retraction.

B307-Strat' pg-jump

"To find   a scapegoat 

            is to be  spared ...

               any necessity  for further

                       examination  of the facts ..."

Fredrick Lewis Allen,   Since Yesterday,    p 234 .      

Oct' 1990 alsp-Petition against NTSB AAR 81-8

  John …   handed     Ron Schleede  a copy   of    the Petition.      

After flipping through the document   and   appearing   indifferent    to its contents,

                                                                      Schleede  set   the petition   down on his desk.

         [Schleede]   said  something about   being  very busy and  not  having  much time  to look at it."

1990    -->  1991   -->   1992   -->   1993   -->   1994

  -->   1995               

         NTSB   staff     buried   the Petitions

   against  their AAR-81-8

 ". . .   On   December 2, 1991,   Trans World Airlines,  Inc.,   filed a petition . . .

TWA’s stated purpose of the petition was to

 'finally  put to rest  the questions-raised   in   the  petition of Captain Gibson...'  

The  TWA petition  is also   being handled  independent  of

the subject  petition from Captain Gibson. . . ."      

       [NTSB   acknowledged   the Petition from   the airline,  May 4,  1995]

Ron Schleede, an NTSB Staff-Manager

   Mishap    investigations

Yaw x Roll =  DIVE !

  --   1990   through    1999  --

Refresh  your  awareness   of    events

        forcing  NTSB's   investigative-  mistakes,

   with    TWA841    and     AA191  

               during  the spring and summer  of  1979 

             [to appreciate   the stress   on NTSB-managers].

On June 6th, 1979  

FAA  "grounded"  the DC-10 ,

and  NTSB made a deal

                               to solve their lingering  B-727 mystery.

    = = =   

Carefully  fit  together  the  upset  lessons  of the 1990's:  

         with the  recurring   rush-to-judgement ,

             bandwagon   or  ​domino effect ,


misleading NTSB-staff managers .

The   mind-set  of   NTSB  staff-managers'    evolved:

Lacking any training   in the historic

       failure-interactions   from  earlier in the jet-age,

NTSB  favored  Boeing's "analysis"   and   "simulation"

                      concluding  mountain-rotor or,

   human-factors,   and   pilot-suicide

For most of the 1990's   NTSB  

     rejected  any suggestion  of  "discrepant rudder"

          as a possible source  of  a sudden  rolling-moment.  

 - - -

Aviation Week,  July 3, 1961 :

Reporting on the criticism by

            Senate,  committee-staff,

              in late June 1961,

"... proposal   ...  allows CAB

        members   to  delegate   so

 much power   to   subordinates  that  

     persons  dealing with  the board

may be denied 'substantive rights'....

       it is neither desirable

          nor in the public interest

to permit such functions to be

             delegated to subordinates . . .

hot link to section-9 : Yorke's Analysis, his Refutation of The Boeing Scenario
Page-2, attorneys' petition dated 2May91
B307 Strat' pg-jump
Page-33, attorneys' petition, dated 2May91

After   Yorke's  refutation  of   NTSB-AAR-81-8   [ The Boeing Scenario ] ,

      those    three    Petitions for Reconsideration

               had been  accepted  by  NTSB     in  1990  and 1991.

image- Hot Button to 4May1995 falsification of data
Pg-7 Capt's Attorney's Petition, 2May91
Pg-32 Attorney's Petition

  1990   --  1991  --  1992  --  1993  --  1994


  NTSB  staff-managers    Buried    those   Petitions

  "... a few talented pilots,  engineers,   and aircraft accident investigators . . . 

          their refusal    to cynically accept     the corruption of their craft . . ."
   ". . . do we need   a public agency   like the NTSB . . .

Attorneys' Petition _HG_Gibson
Page-6, attorneys' petition dated 2May91

Tuesday, October 29th, 1996   B737  ground-test,

    at the Boeing Flight Test Center (BFI)

       Jim McRoberts  discovered a flaw

            in the ship's  Rudder Control System.

December 19, 1997   SilkAir   MI185   B737  

               CRZ   inflight upset,  dive, inflight breakup.

   --  NTSB's  11Dec2000  arguments against  the Indonesian AAR,

             asserting instead  Boeing's claims that

                  the Asian pilot (non-white) had caused  a suicide-murder ,

​                      as AAR  Appendix N,  signed by Chairman Jim Hall.

March 24, 1999   NTSB-AAR-99-01,

          final  report on B737 accident of 8Sep94

                       also  included  NTSB's  implicit  retraction of  the AAR-92-06.

March 27, 2001   NTSB-AAR-01/01,

               "amended"   the earlier  AAR-92-06;

                      AAR-01/01    P.C. = "... rudder surface  ... deflected

                                                               ...  direction opposite ..."​​

Page-9, attorneys' petition, dated 2May91
707 exemplars -- page jump
Page-22, attorneys' petition, dated 2May91

the   slice  to  vertical

Yaw x Roll =  DIVE !

  --   1990   through    1999  --

In  October  1990  Yorke's  refutation   of   The Boeing Scenario

           was formally  presented to NTSB.

The   Air Line Pilots Association,   Accident  Investigation Department,

   led by  Harold Marthinsen,   sent  copies  of that  "alpa" Petition

      to its  pilot-investigators,   offering Yorke's  powerful insights

                                                about   "discrepant Rudder" upsets;

sourcing the obvious effect (roll)  to    Beta (cause)

explaining   the slice  into a steep dive  event                  

without any  A.N.D.  pitch-moment.  


Before   the B737  upset   at Colorado Springs,

           alpa's pilot-investigators  had been taught about

                   upset lessons:  the cause-effect entanglement,

                            misperceptions,  in  discrepant rudder  upsets.

On  March 3, 1991  a  Boeing 737-219,  N999UA 

                    upset-DIVE-impact near Colorado Springs:

 -- the  early  mountain-rotor  theory, Boeing's simulations;

​ --  the  16July92  Rudder-Pedal  delay at ORD;

 --   NTSB's  4Aug92   reprimand (after a Rudder theory);

 --   Boeing's  8Oct92 meeting, "we have a problem";

 --   NTSB AAR-92-06,  dated 8Dec92   (with  no Public Hearing)

May 28, 1991  Lauda B767  violent inflight upset,

                                      inflight breakup,    Thailand.

June 6, 1992 Copa  B737-200 upset- dive- inflight breakup.

April 11, 1994   Continental  B737-300

                                violent roll upset, loss-of-control.

September 8, 1994   US Air    B737-300  N513AU

                                  upset-dive- impact.


Page-21, attorneys' petition, dated 2May91
Page-33 bottom, attorneys' petition dated 2May91

  1990   --  1991  --  1992  --  1993  --  1994


  NTSB  staff-managers    Buried    those   Petitions

1990    and    1991

 Multiple Petitions  Filed  against  

                                         NTSB's    AAR-81-8  

John Rohlfing, TWA-alpa, Accident Invesigation

Petition of Captain H.G. Gibson 

  First submitted  to   NTSB  on    May 2nd,    1991;

                 by   three attorneys, 

                                      against NTSB's AAR-81-8. 

Then  after  years of   NTSB  refusal to respond,    attorney's    submitted  it   to courts     for legal intervention.

This Petition served as: 

  ---  an §845.41-Petition for Reconsideration

                            directed at USA's NTSB AAR-81-8;

  ---  and as  the source document for

                            court action against NTSB's persistent negligence.

This Petition (dated 2May91), collated by attorneys,

                                                differs from other petitions: 

This includes records from post-accident court trials.   It offers testimony from Boeing engineers who created the written draft of The Boeing Scenario.   And this petition offers testimony from the NTSB's Investigator-in-Charge (IIC)  "Dean" Kampschror.  

In addition, this petition offers a 

        forthright   account of NTSB's investigative biases,  mistakes.

Investigators  (instructors and students)   can learn from  NTSB mistakes.  

 This   petition   includes a nice essay about

      "the corruption of the craft"    of mishap-investigation, and

                             the  professional outrage against  NTSB corruption.  


  ? Err recognition?     ?

               -- Learning   from   mistakes?

                           --   inside   NTSB

Acknowledging  NTSB err :  a  proposed section in AAR


Tax payers'  investment in a new 

        NTSB Training Center --  but  no err recognition,  

                                                      no  instruction on investigator-err,

no  schooling  on  scientific misconduct.    

Page-8, attorneys' petition dated 2May91

In Oct'  1990,     John Rohlfing       (from TWA-alpa)

     HAND-CARRIED  that     "alpa" Petition    around

             to NTSB- Board Members,      AND      

                                               to   NTSB's   staff-manager  Ron Schleede.

Sci-Misconduct Taboo Issue ?
AAR-81-8, pg-1
Correcting the Science Record - jump pg
Page- 20, attorneys' petition, dated 2May91
cover-page, attorney's Petition (to NTSB then to courts)

After years  of   NTSB  non-compliance  with  their own  rules 

       on   handling   Petitions for Reconsideration,

                the   mishap-pilot     elected to   PAY    for  outside   legal  intervention,

                                                                                          into the   NTSB's  hidden  process, 

                                 hoping  to   correct    errs   in  NTSB AAR-81-8.

On   January  13th, 1995,     the pilot's  attorneys    filed  legal action against  USA's  "independent" Safety Board.

_Av-Week_, July 3 1961 : Board may deny substantive rights
button --> NTSB's Cover-up

... Kampschror denied this...

but under cross-examination ... the Boeing expert ... admitted that    on  June 6, 1979  ...

 NTSB's   Kampschror  

 asked  Boeing  to propose ...   description  of   what had happened.

Page-1, attorney's petition dated 2May1991

10 -a

Page-5, attorneys' petition dated 2May91

"… October …  1990 . . .  

       ALPA’s  ...   Petition for Reconsideration

              was ready  for submission.

   John  Rohlfing  …   was eager to present  the Petition   to the NTSB....  

      he flew to Washington D.C.,   to hand deliver it…..

                  he had   several copies  of  the petition   with him … 

…  arrived in Washington.    He told  the secretary who … and why  they were there.

  The men were then escorted into   the offices of   Ron Schleede,

                            the   Chief of   Major Aviation Investigations     at the NTSB.

NTSB  AAR-81-8

June 9th,  1981    

pg - by - pg   images


              1990    and    1991

  --  Multiple    Petitions    Filed  against  

                                         NTSB's    AAR-81-8