Failure - Interactions

Correcting the Science Record --> pg jump
1990s Petition button --> pg jump
Button NTSB's COVER-UP phase --> jump pg

Glines'  history of the  INVESTIGATION    is divided into  sections  linked  below:

  The  INVESTIGATION:  

        B-727  N840TW,   TWA841 / 4Apr79

             The USA's    "independent"    Safety Board   (NTSB) 

                --   Organizational "System Failures"


This review  of  a B727   mishap,  and  review of the USA's  investigation  of that mishap,    follows the   history  as  presented  by writer  C.V. Glines.  


Along side of   excerpts  from  Glines'  story  are  shown  other  excerpts from  the various documents,   and  from analysis  by various  outside sources,  and excerpts from  press stories   at the time.   This B-727  INVESTIGATION   was  covered by newspapers and TV,  the rumors retold,  new press stories and books  reported on   the investigation,  

     -- NTSB refused to  published  any errata sheets,  

     -- the NTSB refused to   retract   AAR-81-8, 

           even after the Board had voted  to retract   AAR-92/06   regarding UA585 at COS.  


Several  mishaps involved  an inflight loss of control best characterized  as  Yaw x Roll = DIVE:  a subtle "slice-to-vertical" inflight upset,   with almost  no pitching-moment,  yet resulting in a very nose-low attitude  (a subtle 1-G initial upset),    induced  by  a  "coupled"  yaw and roll motion.


Glines'  original story, "The Nightmare Continues",  was published in the Fall of 1981.  Excerpts from that magazine story  appear    mostly in chronological sequence,  and the excerpts are divided into investigation phases,  with excerpts  pasted into the following web-pages  (pages numbered   #2  through   #8 ).   The web-pages  numbered   #9  and   #10   show excerpts from later reports, describing the efforts to test the NTSB's compliance with  §845.41   Petitions for reconsideration ,    and later  legal efforts to force the USA's Safety Board to comply with their own rules (and Major Investigations Manual), and to comply with the US laws.


Web-page #10    also  includes  excerpts   describing the  "investigation safeguards"   in use by the  investigating authority  of other countries.    The NTSB's  investigation of TWA841  ran from early 1979 until mid' 1981,  before  terms  like  Scientific Misconduct   had been defined.   Even now, in 2014,  the definitions  of  "scientific integrity"  and  "scientific misconduct"  are not recognized  in  the training programs for "accident investigators",  and the training materials provided by outside organizations  are not directly aimed at  the craft of "accident investigation".    The USA- NTSB hasn't yet  complied with the  USA's  OSTP rules for acknowledging reports of Scientific Misconduct.  Nor has NTSB nor OSTP set any guidelines against  "Scientific Misconduct"  by a manufacturer acting as a "party" to an investigation.


Excerpts from Glines' story appear mostly   pasted on the left side    of the following web-pages, as shown just below;  excerpts from related press stories  are pasted on the right side.  Pdf- copy of  Glines' history are linked below,  and  also available are a  page-by-page  display  from the original magazine issue (click on excerpt).


    Air Line Pilot

    magazine excerpts,   Oct'1981 pgs 9-11, 

                                  Nov'81  pgs 6-10, 31, 33

​                            pdf is  4.5Mb

C.V. Glines' opening paragraphs, Air Line Pilot_ , Oct' 1981 , p9

This    "NTSB- investigation"    

from early April 1979,   to  June 1981  

 

      --  through the first attempted   "Sunshine Act"  Board Meeting  

             on January 17th, 1980       (Board Members did not agree to

                                NTSB-staff's recommended P.C.);


      --  Then  the investigation  dragged-on,   through the

            election of Nov' 1980,    and through the

              inauguration of a new president in Jan' 1981;


      --  until   two of three   Board Members  agreed to  

            the same  "Boeing Scenario"    that the Board  had  

                                                       rejected   more than a year earlier.


      --  the  final  P.C.  for  NTSB AAR 81-8  was endorsed on June 9, 1981,  

             at a second attempted   "Sunshine Act"   Board  Meeting

                                                 (only three Board Members attended). 


   Until the mid-1990's,   this    INVESTIGATION    ranked   as  the

          longest  and  most expensive   case  in the then history of the NTSB.

. . .

Lessons from the Boeing-led

NTSB  INVESTIGATION
of a typical "mysterious"  airliner     night      inflight upset

Night    FL390    CRZ       Yaw x Roll = DIVE

B727     N840TW      TWA 841 / evening of April 4, 1979

. . .