Failure - Interactions

Voice Recorder

wires disconnected,

CVR removed

from aircraft.

Col.  Paul  Turner

CVR Specialist.

The  FAA -- the Regulator -- not only  checked  the airlines (aircraft and pilots).   The FAA's   Seattle  ACO  (Aircraft Certification Office)  had  certified the B-727:  Note  the FAA  certification-pilot,  Earl Chester,   in this video recording of the  April 12  "public deposition" --  Earl is next to, and conferring with   FAA's  party   "spokesman" -- an attorney.

Philosophy  of   questioning  witnesses:

interview   rather than    interrogate.

Many viewers did not  recognize   that   the USA's   FAA  had a strong motive  to defend their  certification of the B-727.  Observers  failed to appreciate   that  NTSB  allowed  this FAA-attorney to inject   his

cross examination  techniques   

into  the   interview  style   of engineers and pilots.

["Crew Interview",  Aircraft Accident Investigation Procedures and Techniques.    Oklahoma City, OK.:   Federal Aviation Administration Aeronautical Center, May 1978, p 55.]

Later,  during the  October 2nd, 1980,   Boeing  flight test aboard the company's  B-727  "E209",  that same  FAA certification  pilot  (Earl C.)   flew with  Boeing's  Chief Test Pilot:   the Boeing pilot and that FAA pilot  produced the flight-test   "data"     used  to  prop-up   the NTSB's  favored  conjecture --

the Boeing Scenario.

Boeing,  and   FAA,   were  bound  together   in their efforts  to defend  their   certification   of  the  B-727.

an early   "deposition"

       Thursday, 12Apr79 --

  Inglewood, California, City Hall.  

The NTSB conducted a public "deposition" of  three mishap-pilots,   staged as a media event:  with each individual pilot  confronted by TV lights & cameras, with twenty-six microphones.          Then one-by-one,   each individual pilot  was forced

              into his own   "perp-walk"    toward  a seat   in the middle of   the ring of inquisitors.

Each mishap-pilot answered questions from 

NTSB,   Boeing,   TWA,    and   one  FAA  spokesman.  

This  setting   for this  NTSB   "depositional proceeding" 
violated  NTSB's  Order 6230.18,  dated 27Sep78,   which required
 the deposition site    "shall be chosen carefully to create  an informal environment  and
 not   take on  either  appearance or formality of a hearing."
NTSB  managers'    Procedural Non Compliance    (PNC or "pink")    continued,
always to the benefit  of Boeing. 
In his opening remarks at 10:20am, Kampschror (NTSB)
     introduced himself as   "the designated   Board representative",   and 
   he introduced  Fred Rathke (CHI Field Office)  as   the Investigator-in-Charge (IIC).
            [A few weeks later Kampschror  began serving  as the IIC   displacing  Fred Rathke.] 

Kampschror  stated that this was   not   "Public Hearing"    [as defined in §845.10],   

                                          and it did not qualify as a   Public Hearing   [per §845.11]:  

​Thus there were none of the usual procedural safeguards  customary of a formal Public Hearing,

       no Board Member attended this depositional proceeding

              nor had there been any Board Member serving on-scene at  DTW

                                                               [no Go Team  went to Detroit].

  In contrast to the    "interview" style questioning   from NTSB staff and Boeing (all engineers),  the longest interrogation was by the FAA representative (an attorney),    mostly in a hostile manor of an enforcement proceeding.

NTSB   allowed  that  attorney  to act as  "spokesman"  for FAA :

                                          that  attorney dominated  that  NTSB proceeding.

     This  mismanaged  NTSB   "depositional proceeding"  added to the earlier  breakdown  of the NTSB's "safety investigation",     by mixing-in assertions of crew misconduct -- rather than considering the usual engineering  fault-analysis of  the preexisting latent-failures in N840TW's subsystems.

CVR and FDR  installation on N840TW:

Both Recorders were installed in the Aft Cargo Compartment,   adjacent to the Aft Cargo Door  (mounted in rack on RHS wall)

CVR control head

   On Overhead Panel

         above & behind the pilots' inboard shoulder (up).

. . . 

Excerpts from Ch 8,    

"Roll out the Barrel"

From pg 207:

. . . A number of points surrounding the incident were also found questionable by members of the inquiry.   To begin with, the cockpit voice recorder tape on the 727 had been erased after Flight 841’s emergency landing at Detroit.  CVRs are not permitted to be used by the FAA in any disciplinary action.  The recorder tape operates on a continuous, thirty minute loop and would not have recorded details of the dive, but the NTSB were suspicious that conversations on the flight deck after the incident could have revealed details of the crews’ actions and were deliberately erased. . . . Most pilots feared misuse of its information and regularly erased the tape after a trip.  Under questioning by counsel, Captain Gibson admitted that he, too, normally erased the tape after a flight but that in this instance he could not remember doing so.

From pg 208:
 . . . The investigating team clearly felt that the erasure of the CVR was deliberate.   If the inadvertent operation of the number seven leading edge slat was also to be proved part of a deliberate act by the crew,  then any mechanical failure of components would have to be discounted. . . . 

From pg 217:

At the beginning of the inquiry, suspicions of malpractice were initially aroused by what appeared to the investigators to be the deliberate erasure of the CVR by Captain Gibson.   The crew, the NTSB surmised, must have had something to hide.  Erasure of the tape by Gibson, however, was clearly shown to be impossible.  The CVR can be erased by the pilot only when the aircraft is safely on the ground with the parking brake set.   Squat switches on the landing gears contact when the oleos compress with weight, closing circuits which confirm the machine is on the ground.  
The high speed lowering of the Landing Gear during the upset,
  resulted in damage which tore the squat switches and circuitry from the structure and
. . . . . . . . . . the 727 landed with both main gear lights glowing red.
 The CVR erasure circuit was incomplete and,
. . . . . . even if the captain had pressed the button on the flight deck,
. . . . . . . . . . . . . nothing would have happened
Gibson could NOT have deliberately erased the tape and
the NTSB’s initial suspicion that he did so because he had something to hide, was unjustified
- . . -xxxxxxx
​What is more, this was known and understood by the investigators early in the inquiry.   Also after erasure, the tape recycled and a further nine minutes of conversation, including statements relating to the incident, were recorded.  If it had been Gibson’s intention to erase the tape, and it had been physically possible to do so, it is most unlikely that any evidence would have remained.  So how was the tape erased?    ‘Popular Mechanics’ magazine interviewed a CVR technical expert and revealed that on a slow transfer of electrical power from the 727 engine to the APU,   which Banks accomplished on this occasion,   erasure of the CVR is possible.  This is the only way in which erasure of the tape could have occurred.  The timing of the tape recycling and the moment of slow power transfer also corresponded, as did the ending of the recording, nine minutes later, and the shut down of the APU.


NTSB AAR-81-8,  pg 33:

   "... the Safety Board believes . . . the captain's  erasure  of the CVR is a factor we cannot ignore and cannot sanction."

False  information    AAR pg 6

Never   any  fault  testing  of the CVR

  The CVR-Specialist's Report,  in the docket,  does NOT  show any testing  of the Cockpit Voice Recorder (CVR),

     never done aboard N840TW,     never any bench-test    of that CVR-unit       while at the  lab' in D.C.


Early reporting outlined  

alternative hypotheses

for the INITIAL upset

During the first week after the mysterious inflight upset,   at the earliest NTSB-interviews,    crew had  described a  "popping sound"   at the very beginning of the INITIAL  upset   [an audible  characteristic of   engine  compressor-stalls   during  sudden   sideslip-angle  Beta].

  CVR:  the Smoking Gun

       --  focusing on the  second week of April'79

NTSB permitted   FAA's  attorney   to  stun  the  crew with   cross examination   techniques

during an  NTSB    "safety"   investigation -  "depositional   proceeding".

_Air Line Pilot_ , Oct' 1981 , p10, bottom of 2nd-column and top of 3rd-column .
"Smoking Gun" ; _Air Line Pilot_ , Oct' 1981 , p10, 2nd-column, mid-pg .


  a week later 

By the end of the first week of April'79,  the NTSB had found that the Cockpit Voice Recorder (CVR) magnetic- tape,  aboard the mishap-aircraft,   had been  degaussed  after exposure to  an electromagnetic-field.  The NTSB's CVR "specialist"  (Paul Turner)  inferred  that the tape- degaussing  had happened "while parked"  due to excitement of the recorder's own  "bulk erase"  sub-system.     Turner's report stated his   inference as   instead  a fact,    his wording threw suspicion on the  mishap-pilot,   implying an intentional act   by the pilot   done after landing   [for example,   a pilot pressing the ERASE button in the cockpit].   

Then on  April 12th,   in Inglewood California (near the pilot's LAX assigned-airport),    the NTSB  hosted a "depositional proceeding"  permitting the various parties  to

  cross-examine   the three  mishap-pilots    (done most aggressively  by   one FAA attorney).

Lessons from the Boeing-led  


B727   N840TW     TWA 841   /   4Apr'79