Failure - Interactions

NTSB-investigators'   Confirmation-Bias 

and  citing   early assumptions

 as  instead   "findings"

… NTSB staff  report’s  author,

Leslie D. Kampschror,  investigator in charge,

told the board at the open meeting June 9  

that he had obtained

“no direct evidence”   to prove that

the crew  had   manipulated the controls.
    The staff  used   a process of elimination   that

ruled out  mechanical failure   to conclude that

the crew must have taken

some action that extended the slat….

"The safety board ruled out . . .

because of complexities involved . . ."


Note the INVESTIGATORS'  hidden assumption:

 there were   NO POSSIBLE 

"double  failures",

 NO  failure-interactions

just prior to INITIAL upset.


As a counter-exemplar,   where  other  investigators  explicitly  listed  their assumptions,

and   investigators  considered

a  possibility of a double-failure,

 see the investigation of  

Sabina B707 /  15Feb61   (bottom, causes)

The NTSB's  "findings"   and   their  Boeing  P.C.

         were  in conflict  with   the   "facts"

              offered by these  pilot- witnesses

_Aviation Week_'s  final report in June 1981

      _AW&ST_  had refrained from reprinting any of the rumors, gossip, and
            misinformation found in other  newspapers  and  magazines.

                      _AW&ST_  had  reported on this mishap-investigation    in only two other issues of the magazine,  during  Apr'79.


 The Board had   rejected  this  same

Boeing Scenario

at  their  first  "Sunshine Act"  Meeting,

on January 17, 1980.

Neither the airline,    nor the Regulator  (FAA),

     found any  evidence  of  any wrong-doing

         by the mishap-pilots:  

             only the NTSB's  vague  inferences  

                    retained  from  "the Boeing Scenario".


_AW&ST_  report   on NTSB's   second  attempted

     "Sunshine Act"   Board Meeting  of   June 9th,  1981.

     "Crew Cited in TWA 727 Incident",  

            _Aviation Week  &  Space Technology_.   (June 15, 1981),   35.