Failure - Interactions

The  NTSB  §845.41    process,     Petition for Reconsideration

        has been repeatedly  blocked by NTSB's   entrenched   staff-managers

                deferring  any of   the  corrections    cited in   the Petition  of Oct'1990.   

The process  for    NTSB's  response    to Petitions (845.41)   has   FAILED

   (is unworkable without some outside oversight),   and

the detailed steps required  by   the NTSB's

         Major Investigations Manual    (4.15, Apdx Q, Order 600A)

  have been ignored by NTSB's staff-managers   and

  ignored by  the  political-appointed  Board Members.

June 1979:   NTSB IIC's   hidden-assumptions:

no  probable   failure-interactions.

Cottta, R.    "The Case of the Extended Slat."

     Aviation Engineering and Maintenance Magazine

                 (June 1979),   p14-15.

Late May 1979 --    Industry in turmoil,

airline service in disarray,     passengers stranded:    

          DC-10 crash   on   Friday,   May 25, 1979    at   ORD.

                  FAA's  certification standards  attacked.

                 NTSB's  investigator-err of Sunday May 27th 1979.

                  Retracted their  investigators' err on   Tuesday May 29th.

Early June, 1979     A series of FAA AD's  for DC-10 inspections 

                                   inhibited airline capacity,       travelers  grounded.

On  June 6th, 1979,  FAA's Suspension Order  grounded   DC-10  fleet.

On   June 6th, 1979,    NTSB's Kampschror  arranged for 

Boeing's R.A. Davis  to provide  conclusions for B-727 N840TW.

pdf 7 Mb     Trial Testimony:   NTSB-Boeing  deal  of June 6th 1979

JJ O'Donnell's letter,  to Chairman King,   dated April 2nd '81:

"... there has not been one substantial shred of evidence of any crew error or wrong doing ... crew has suffered from  a malicious,  unfounded rumor ... This is especially anguishing   when through extraordinary professional skill the crew was able to save this aircraft  and the passengers . . ."

"Infusing moral values

into science ..."

NTSB's Investigator-in-Charge, later telephoned the reporter, admitting that  during that interview,   he (the IIC)

 had  merely  recited  the early RUMORs -- about a non-existent   technique.

''The Plane That Fell From the Sky,''    CBS Reports,   Wednesday July 14, 1983, 10pm EST

_Newsweek_,   April 16th, 1979,   pg 53.

 Deception  &  Misinformation  

as  practiced  by a  nation's   investigating-authority

Gossip,   Rumor  -- as a basis for Hypothesis.


   The     NTSB  Chairman   responded:    

         "We do not believe that the  integrity  and  credibility

                                of this investigation has been compromised"  


   November 19th, 1979,   NTSB's Chairman responded,

             Chairman King  wrote ALPA's President:

  ". . .  As you know, we have a short and clear policy

                    prohibiting investigators from discussing analysis or conclusions. . . .  

  ". . .  Specifically, the quotation    that there has long been an  'unofficial procedure' 

              concerning partial extension of trailing edge flaps is erroneous. 

                   Our investigator has no way of knowing that such a procedure exists. . . .

  ". . .  The quotation,   'I assume they're hiding something, . . .'  

     Our investigator's recollection is . . .  he replied that he did not know

              whether they were  or not     and that there were

                           no facts indicating that they were hiding anything.

  "We regret very much any discomfort the article may have caused the flightcrew.

     It is indeed unfortunate that the article purported that conclusions

         had been drawn which involved the flightcrew.  

              However,  we do not believe that the integrity and credibility

                              of this investigation has been compromised in any manner. . . ."


       Repeatedly during the  long  ntsb- investigation, 

ALPA    cautioned   NTSB  Staff  and  Board Members

that  their   initial  assumption was  merely  a  RUMOR.

  Below are  two  warnings  sent in the fall of 1979,  to the Safety Board,  about  NTSB's  rumor-mongers;   then    the  April 2nd, 1981,    letter from   the   President  of the pilots' association,           

  again pointing-out   that   their early  rumor,    repeatedly  retold  as entertaining  post-mishap GOSSIP,   had  become  widely accepted   as instead   a  fact:         

                              the   NTSB  managers had   tainted their own  investigation.

  Below  is the   testimony  from  the  reporter 

      who had interviewed  NTSB  employees in September of 1979. 

The NTSB's  lead investigator, "Dean" Kampschror  (then Colonel since 1971  &  promoted  shortly afterward  to Brigadier General),   had  earlier  flown with  a local  USAF- ANG  squadron (out of Martin Field near Baltimore),   and was in 1979 currently flying with the local 121st TFS at Andrews AFB.   The Investigator-in-Charge asked airline pilots from his  various  squadrons:   But  NONE  of the airline pilots had ever heard anything about   Col. Kampschror's   rumored  "unofficial procedure". 

                   His  rumor  was   a  fabrication.    

Kampschror's  testimony is  shown  below:

  according  to  Kampschror's  RUMOR,  

there has long been an   'unofficial procedure'

[As quoted,  from his interview in Sept'1979, 

then printed in the Oct' 15th edition of Aviation Consumer magazine.] 

There was   no    "unofficial Procedure" 

    --    Just  a  normal   post-mishap    Rumor  --

--   Misinformation    from   USA's    "independent"    Safety Board  -- 

  and  this   post-mishap Rumor  was  not  long standing

    Kampschror   later   backed-away from his  earlier   assertions, 

                      and   admitted   it  was  only  a   rumor.

The   transcripts  shown below are from the   post-accident  litigation.    Attorney  Donald Chance Mark   questioned  both the NTSB's lead investigator,     and the reporter  who had interviewed those NTSB  employees.     

 according  to  Kampschror,  

there has long been an   'unofficial procedure'

[As quoted, in the Oct' 15th edition of Aviation Consumer magazine.] 

After the completion of the NTSB's investigation of TWA841 (in June'81),

                 then began  various court cases.  

During litigation,  one attorney,  Donald Chance Mark,  

pursued   the origins of   this  rumor    that  had   strongly

prejudiced   the    NTSB's   lead investigator   (IIC) --

  blossoming    gossip    about   pilots'   purported  "unofficial  procedure".  

Kampschror was questioned   by various  attorneys during  long depositions,  extending over several days.   The questions,  and the NTSB attorney's  obstructive interruptions during these questions,   throughout the legal transcripts,  makes for  tedious reading.   Eventually, the transcripts reveal  that Kampschror   had discussed  this rumor with several  working airline pilots,  at various airlines,  but he never found any  airline pilot who had even heard about  this "unofficial procedure";   and eventually during his extensive testimony  Kampschror    backed-away  from his earlier statement  about  a long-time "unofficial procedure",   and he acknowledge that   investigators  never  found any evidence that there was  any such procedure used during CRZ flight  in any jet airliner.   


But  during the NTSB's   INVESTIGATION,

    that   rumor    became   accepted   as   "fact" :

  At the first attempted   Sunshine Meeting   of the Board Members   on  Jan'17th, 1980,  transcripts show that  staff-engineers  first explained to Board Members that 

it was  only a rumor;    then immediately thereafter

one Board Member contravened  the staff's finding --

       by  declaring that   the rumor   was instead   a fact.

  One version of the early rumor remains preserved in the  "Conclusion"  

       and the "Probable Cause"  statement  of NTSB AAR 81-8:  

                            NTSB  never retracted their  AAR-81-8;

                                    no errata -sheets  nor modifications

                                                of the Board's initial AAR have ever been issued.

  Lesson for investigators 

  -- The  Role of  Rumor  and   Gossip  --Deception   and    Misinformation

After  an  unexplained 

"mysterious"  Accident,

during the prior seven decades.

 according  to  Kampschror,  

there has long been an   'unofficial procedure'

[As quoted,  from his interview in Sept'1979, 

then printed in the Oct' 15th edition of Aviation Consumer magazine.] 

Continued --   from  Oct'81 issue,  pg-11,  of Glines'  story.

Post-mishap  Gossip  about   pilots  deploying  TE-Flaps  during  Crz.

  according  to    NTSB's   Kampschror,  

there has long been an   'unofficial procedure'  

September 1979 --

The NTSB's Investigator-in-Charge  (IIC)

Dean Kampschror was interviewed

by a reporter from  _Aviation Consumer_

The IIC's comments were later published in the October 15, 1979 issue of that periodical:

  "According to the NTSB's chief investigator on the accident, L. D. Kampschror

          there  is no evidence of any mechanical malfunction.  

       'I'm satisfied that there was nothing wrong with the airplane,' 

          he told the _Aviation Consumer_

        'And   Boeing tells us it's impossible for

               the slats to pop out   because of aerodynamic loads.'

"Other factors point the finger of suspicion at the crew.    After the 727 had landed safely, Capt. Gibson inexplicably erased the cockpit voice recorder, which would have revealed the crew's conversations after the incident.

Second,  according to Kampschror,  

  there has long been an   'unofficial procedure'   among some 727 pilots for flying at extremely high altitudes.  At 40,000 feet or so, the air is so thin that the 727 staggers along at a rather high angle of attack.  Hoping to improve high-altitude cruising performance and handling, adventuresome 727 crews have been known to deploy the first notch of flaps (2 degrees),   which increases the effective wing area and might theoretically allow the airplane to cruise more efficiently.  However, four of the eight leading-edge slats automatically deploy when the first notch of flaps is selected.  Since it's obvious that leading-edge slats are a no-no at Mach 0.80,  part of the unofficial procedure is to   pop the circuit breaker   for the slats so that they'll stay put during the flap extension.    This gives the desired trailing-edge-flaps-only configuration.

But it's not hard to imagine what would happen if the flight engineer popped the wrong circuit breaker.

The crew has made sworn statements to the NTSB that they did nothing of the sort,

           but their arguments apparently have not been too persuasive.

      'I assume they're hiding something, but I can't prove it.' 

          NTSB Investigator Kampschror told the Aviation Consumer

               'We're wrestling with that problem very hard right now.'  

Another NTSB spokesman voiced similar doubts,  

      'I think those guys were fooling around up there,

                and I don't think we really know what they were doing yet.'"  


        states the NTSB's bias

  By the summer of 1979, the NTSB's  IIC   had  fixed upon the 

     rumored  Boeing Scenario as "cause"  for the INITIAL  upset.

  Without a strong engineer-investigator

       to challenge their misguided IIC,

         the NTSB's investigators   never  corrected their

                erroneous course set by the  manufacturer.

_Air Line Pilot_, Oct'1981, pg-11, center column, 2nd-paragrap
_Air Line Pilot_, Oct'1981, pg-11, center column, 3rd-paragraph
_Air Line Pilot_, Oct'1981, pg-11, center column, first-paragrap

Lessons from the Boeing-driven  


Night     FL390      CRZ        Yaw x Roll = DIVE

B727    N840TW,   TWA 841   /   4Apr'79

The  INVESTIGATION  -- during  late-spring  and summer of 1979