tdracer calls our attention to a couple of factors …
the FIRST thing we were told at the beginning of the investigations was that we were not allowed to publically release ANY information with regard to the investigation until the NTSB had issued their report - we were even discouraged to discuss it with co-workers other than to get additional technical input. Failure to abide by those instructions by an individual would result in severe discipline…
… IGh calls our attention to other factors …
… There were several other comment-ers here, who stated that they hadn't noticed any weakness inside NTSB investigations. These investigator-errs are mostly subtle, with the respected manufacturer's submission leading the poor NTSB staff -- and then omitting the crucial information that might properly reveal the design-weakness…
… and Dozy directs our attention to other slightly different factor …
…(w)ith all due respect, I think you're letting your (justifiable) bad feeling regarding the Gibson incident lead you to assume that all investigations follow a similar path, when that's not the case. Obviously in that case, the lead investigator didn't follow up with enough vigour on the alternative propositions put forward, however that was but one investigation…
…and I fully recognize the accuracy of IGh’s comment that …
this verges into a thread-drift away from any UPS mishap…
..but, I believe these comments ARE well-meaning … and, unfortunately, accurate – at least enough times to be aware that they exist. So, with any apologies that might be thought to be appropriate, I think that the point being made here IS, the following:
1) any (…and I mean ANY…) governmental organization or any company where there is … or there is the potential for there to be … severe scrutiny by “outsiders” … particularly when those outsiders are in a position to register objections or express disappointment or disapproval of whatever is or has been done, including the process used and what is or is not considered … (particularly if the “higher-ups” within the organization being complained about either are or could be concerned about continued funding, continued staffing, appointment reconsideration, or even “re-election” if those objections, disappointments, or disapprovals are allowed to progress) …
2) it is almost guaranteed that the issue is very likely to be downplayed, expressed in a manner that it might be overlooked or unrecognized, or, in some cases, re-worded in such a way that one could continue to argue for its retaining its initial meaning, or finally, in extreme situations, even “inadvertently omitted,” but, in any event, if presented at all, could easily be read and/or interpreted with a much lower level of recognition or concern as having had any large degree of influence on whatever happened.
It might be necessary to re-read the above thought to understand the point I’m attempting to make. From my perspective at least, the above kinds of situations happen with at least some frequent regularity. Again, the bigger the cause for the examination, the bigger the “hoopla” that could be generated … and this, more times than not … results in the bigger the “effort” being expended in doing whatever is deemed necessary (any or all of the above) by those who see themselves as having to make the largest correction, or those who might be “hurt” or “embarrassed” (or both) to the largest degree.
The fact is that sometimes, very well meaning professionals are either swayed by some aspect of an investigation, or are not listened to by that person’s superiors – regardless of the employer. Some people examine “facts” and reach conclusions that are diametrically opposite the conclusions reached by others looking at exactly the same facts. Some of you may recall the extensive posts I made some time ago regarding the Air Florida, B-737 accident at the 14th Street Bridge, after takeoff from Washington National Airport, Washington, D.C., on January 13, 1982. The same NTSB discussed in this post was the NTSB that performed that investigation. The FAA tower controllers, Boeing, Pratt-Whitney, Air Florida, the pilots flying the airplane, several persons or companies providing ground servicing, and others, were either directly or indirectly involved. Some of the interviews and some of the statements that were gathered did not appear in the report. Some other information that was gathered and did appear in the final report did not play a part in the final determinations or recommendations. Additional information, thought by some to be extremely relevant was completely disregarded. Some facts were included but apparently were not considered to be relevant by some professionals, and other professionals considered those facts to be pointedly relevant.
The point here is that humans are human. And, as we all recognize, humans make mistakes – sometimes those mistakes are meaningful and sometimes they are irrelevant. Unfortunately, we all will not always agree on when any particular decision (regardless of what conclusion is reached) is accurate, partially accurate, or totally inaccurate OR if any specific decision is relevant or irrelevant to the larger issue involved. Knowing all this, it is truly an amazing occurrence when any airplane accident is investigated and any meaningful changes to operating practices are or can be recognized and then made. The only thing we can do is continue to look, learn, look some more, and learn some more … and then apply what we’ve learned in the most advantageous manner possible. And have someone keep a bag packed.