Failure - Interactions
Nov'1999 one rare exception --
a GAO probe for Boeing's hidden safety study,
GAO's Controller General for Special Investigations
responded to a detailed request from one Senate Committee,
The Committee on the Judiciary,
GAO investigated why the manufacturer had
withheld a safety report from NTSB investigators:
GAO's letter, B-283640, dated Nov' 3 1999
Misconduct . . . frauds . . . made
all science look bad, and
aggressively insist they
even though the bias . . .
is well documented.
What to do?
. . . "voluntary withdrawal" and "withdrawal for cause"
instead of ... "retraction" ... which has negative connotations . . .
National Academy of Sciences (NAS)
NTSB Staff-Managers selectively
enforced or ignored the few
NTSB had acknowledged their receipt of the "alpa" Petition against AAR-81-8: date received acknowledged as October 9, 1990.
During that 90-day waiting period, cited in NTSB-845.41(b), Boeing offered no "comment" on Yorke's refutation of the Boeing Scenario.
. . . consider retracting a publication if:
. . . clear evidence that the findings are unreliable,
either as a result of misconduct (e.g. data fabrication)
or honest error (e.g. miscalculation or experimental error) . . .
consider issuing an expression of concern if:
. . . there is evidence that the findings are unreliable but
the authors’ institution will not investigate the case
. . . an investigation into alleged misconduct related to the publication
either has not been, or would not be, fair and impartial . . .
Lack of investigative-safeguards,
along with lack of any oversight of NTSB staff-managers
(no Inspector General, no Scientific Ombudsman, no effective Board Member oversight-review, no Review Board,
stack the deck = to arrange things secretly for a desired outcome. (From card playing where a cheater may arrange the order of the cards that are to be dealt to the players.)
Lack of proper investigative safeguards leaves NTSB-employees, and their "investigation", open to subtle manipulation:
"Stacking the Deck"
John Nance cited this subtle manipulation, done by Boeing, to sway an NTSB-investigation away from hidden weaknesses in their early B737;
Parallel INVESTIGATIONS, to contrast against USA's investigation of TWA841 / 4Apr79:
NZ's Commission of Inquiry, Air New Zealand DC-10 TE901 / 28Nov79
AAIB backs-away from their Review Board investigative- "safeguard"
NTSC's Oetarjo Diran comments.
The proper role of a "Board Member":
to enforce the rules.
Considering proposed reorganization of the earlier C.A.B., summer of 1961, Senate expressed concern that in future "the Board" would:
"... delegate so much power to subordinates that
persons dealing with the Board
may be denied 'substantive rights'. . . .
puts policy making
in the hands of staff members who are not subjected to
Senate scrutiny and confirmation. . . .
it is neither desirable
nor in the public interest
to permit such functions
to be delegated to subordinates . . .
"Senate Unit Rejects C.A.B. Reorganization", Aviation Week, July 3, 1961.
MI185 / 19Dec97 Boeing 737 mysterious inflight upset
Show images -- Feith's words = absolute CERTAINTY, then infecting NTSC-Staff members.
W.H. Tench wrote a chapter on "safeguards" (used by the old AIB)
"to achieve a proper balance in aircraft accident reports":
[Tench, William H. Safety is No Accident. London: Collins, 1985.]
-- a public notice announcing intent to investigate (an inspector's investigation) and invitation to anyone to write to AIB, to suggest relevant aspects of mishap.
-- Before concluding his investigation, the "inspector" must SEEK a Response -from-anyone-accused:
prior to submission of DRAFT report, inspector shall inform everyone whose reputation is likely to be adversely affected by the report, inviting "representations", to argue any point, signify any disagreement [Tench, pg32].
-- a Review Board, a discontented party has 21-days after receiving draft rpt, permitted to ask for a review board; Review Board gives its own separate opinion: both the inspector's report AND the Review Board's Report are then later published within the same cover as the inspector's report. The threat of a Review Board "has a very chastening effect on the inspector who knows that everything he says in his report is liable to be critically examined by a Review Board and, if necessary, corrected for all to see – and this at the whim of those whose actions he is criticising." [Tench pg 33].
-- a Public Inquiry. Tench's exemplar: the inquiry into the BEA Trident G-ARPI / 18June1972 near Stains (near Heathrow), commissioner the Lord Chief Justice Lane. A judicial format: examination and cross-examination; representatives entitled to cross-examine witnesses; close examination of "evidence" (wreckage, data, &ct); testing of "evidence"; representatives' summation of view-points; draft report, publication. "Public inquiries have the advantage that they remove all suspicion of cover-up from any government department. . . . the examination and cross-examination by skilled counsel usually leads to the veracity and relevance of the evidence being established.... the public inquiry system is seen to alleviate public anxiety and concern that there might be something fundamentally wrong with the way certain facets of aviation are being conducted. But it is not all beneficial . . . lawyers . . . an adversary system . . . see things in terms of guilt or innocence. . . . lawyers are always aware . . . inquiry is the preliminary to . . . civil litigation . . . client . . . financial benefit . . . " [Tench p 36.]
-- Refused Board Member's request to hear testimony from the crew,
to test it against the gossip, and thus judge The Boeing Scenario.
Chairman King repeatedly acted against the advice of his most experienced Board Member
James King was an inexperienced Board Member, with no background in accident investigation.
King was apparently responding to advice from unknown sources
-- told to obstruct the efforts of the Safety Board's most experienced Board Member.
NTSB "Board Member" McAdams' corrective efforts were repeatedly blocked by Chairman King.
Among the initial appeals decided by the Chief Administrative Law Judge was the first case arising from
the non-recertification of a career member of the SES. The initial decision affirmed the action of the agency in removing the appellant from the SES and placing him in a GS-15 position on the grounds that
his performance did not demonstrate the excellence required to meet the goals of the SES.
(Kampschror v. National Transportation Safety Board, DC-359C-92- 0290-I-1, July 23, 1992.)
The images above are meant to provide a younger reader with some background on
the power enjoyed by The Boeing Company during the late 1970's and early 1980's:
Boeing was the USA's biggest exporter, and their B-727 airliner was their best selling product.
Shortly afterward, the NTSB's IIC, Col. Kampschror was promoted to Brigadier General in the D.C. Air National Guard,
and promoted into the special SES- Executive Service of civilian Federal Government employees:
... From 1967 to 1975, King served as special assistant to Senator Edward M. Kennedy and was responsible for running his Boston office, setting up field hearings, and frequently traveling with him. From 1975 to 1977, King was director of community affairs and marketing for the Massachusetts Bay Transportation Authority. He took leaves of absence from MBTA in July 1976 to work at the Democratic National Convention, and from August to November 1976 to serve as trip director for the Carter Presidential campaign. Since January 1977, he has been Special Assistant to the President . . .
Mr. Chairman and members of the Committee, the association of the Kennedy family and the King family goes back about 50 years. His father was one of the very outstanding labor leaders in western Massachusetts ... I got to know just after my brother was elected to the United States Senate in 1952. Then through the period of the 1950's, when. . .Jimmy King was a teenager, he was already locked into the concept of Government and public service and public life. . . .
"The deteriorating scope, depth and accuracy of the NTSB/FAA aircraft investigations is approaching the level of a national embarrassment. Instead of being a leader in this field, the United States government seems to be unwilling to provide the resources, leadership or motivation necessary to improve investigative techniques and procedures. . . ."
"There is reason to believe that because of the excessive workload, the inadequacy of investigations, or the questionable nature of some board members' qualifications, some views of parties associated with a particular case are not communicated or understood by the Board's members. Petitions for reconsideration of the determination of cause or, more importantly, for changes in the report to present a fuller presentation or discussion of the facts, appear to be treated summarily without the objectivity which normally characterize the Board's actions. It is rare for the Board to present in its report the contrary views of competent parties unless one of the members elects to write a minority opinion supporting such a view. Such dissents are infrequent."
Perhaps the foremost "safeguard"
(under the supposedly "independent" investigative-system employed by USA)
. . . . . . . . . . . . . . . . should be those individual "Board Members":
acting as a supervisory "overseer", for the integrity of their organization,
overseers of the NTSB's investigators, staff, General Counsel.
Unfortunately, the NTSB's decades-long-process of "reconsideration" of AAR-81-8, repeatedly delayed by staff-managers, proved that the appointed NTSB "Board Members" have no formal responsibility, are not required, to insure that that "process" operates as intended in CFR Title 49, Vol 5, Chapter VIII, Subpart C, NTSB "Rules of Practice" § 845.41.
-- to achieve a balance in the inspector's investigation of the mishap, and
-- "to achieve a proper balance in aircraft accident reports".
Under the USA's "investigating authority", their "independent" Safety Board, or NTSB,
the "safeguards" are missing.
Considering that the "independent" NTSB was established
WITHOUT any IG-oversight of the accident "investigators" nor their process,
perhaps the foremost "safeguard" (under the investigative-system employed by USA) should be those individual "Board Members": acting in a role of supervisory "overseer" -- for the integrity of their organization: overseers of the NTSB investigators, staff, General Counsel.
Keep in mind that the NTSB's INVESTIGATION of the mysterious inflight upset of Boeing-727 N840TW dragged-on from April 1979 until June 1981 [concurrent with the series of Democratic election campaigns of summer and fall of 1980]. Then after the Nov'1980 election through the inauguration in 1981,
(a) . . . the Comptroller General ... shall evaluate and audit the programs and expenditures of the National Transportation Safety Board. . . . at least annually ... as determined necessary by the Comptroller General or the appropriate congressional committees.
(b) Responsibility of Comptroller General. - The Comptroller General shall evaluate and audit Board programs, operations, and activities, including -
(1) information management and security, including privacy protection of personally identifiable information;
(2) resource management;
(3) workforce development;
(4) procurement and contracting planning, practices and policies;
(5) the extent to which the Board follows leading practices in selected management areas; and
(6) the extent to which the Board addresses management challenges in completing accident investigations.
(c) Appropriate Congressional Committees . . . means
the Committee on Commerce, Science and Transportation of the Senate and
the Committee on Transportation and Infrastructure of the House of Representatives.
has ever probed details of NTSB cases,
never recognized nor acknowledged
any of NTSB's investigative-errs
nor any NTSB staff-manager scientific misconduct.
USA's investigating authority has retained its
an undeserved glowing halo of infallibility.
Inspector Generals are NOT permitted to review NTSB-cases
to openly acknowledge any NTSB investigator-errs,
nor NTSB scientific misconduct. .
Note the ambiguous wording about possible oversight functions,
restricting the DoT- IG, and
curbing the work of the Comptroller General [he directs GAO's work];
confused-contradictory restrictions upon any critical-review of NTSB's methods, and
NTSB's final investigative-products (AAR, factors, final P.C.).
(a) . . . The Inspector General of the Department of Transportation ... the mission ... to prevent and detect fraud and abuse, shall have authority to review
only the financial management,
property management, and
of the National Transportation Safety Board . . .
?? a final "safeguard" to protect, or correct, the process of Aircraft Accident Investigation??
Can “the media” or “the Press” — newspapers, TV, radio -- substitute for the NTSB's missing “safeguards” ??
Are journalists capable of protecting the investigation-process from investigator-err or scientific misconduct??
History shows that the answer is "No!"
The exemplar case of NTSB's INVESTIGATION of TWA841 / 4Apr79, to the final NTSB-AAR-81-8,
proved that no mere award-winning documentary,
nor special feature in the Sunday paper,
could persuade NTSB-staff managers, nor Board Members,
to acknowledge their botched NTSB-investigation:
Various ALPA accident investigators (Harold Marthinsen and Jim McIntyre) risked their reputations, appeared on television reports, and in print, in dozens of media stories about that NTSB-investigation. The mishap-Captain also met with writers to explain the NTSB-mistakes. Despite widespread media coverage of NTSB investigative misconduct,
the NTSB staff-managers, over several past decades, were confident of impunity,
with their special scientific-privilege of "unreviewable discretion":
NTSB never published errata sheets, no revision of AAR-81-8, no acknowledgement of NTSB's falsification of "facts".