UPS 1354 NTSB Investigation - CVR
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I hope Machinbird has only 30 minutes drive back home. I guess most of us know what it is after the third night of 14 hours...and a bit tongue in cheek,Cargo terminals very seldom offer You coffee that is younger than You.
Last edited by Naali; 26th Aug 2014 at 02:08. Reason: burnt coffee.
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It is YOUR "independent" Safety Board:
Is this nstb history fair play?
Is this nstb history fair play?
The last thing you want during investigation are squabbles between two parties both issuing public statements. And there was no need to kick out anybody else who participated constructively in the investigation.
And YES, NTSB has been very independent, its track record is spotless.
Pilot's Union is a highly politicized organization, would be at the very bottom of my trustworthy list, I won't shed tears because of their "non-participation".
Last edited by porterhouse; 26th Aug 2014 at 20:39.
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Pilot's Union is a highly politicized organization, would be at the very bottom of my trustworthy list
As if the other parties have no dog in the fight..... Beer me strength....
I've worked with the NTSB on accident/incident investigations, and I've seen absolutely no evidence of bias or impropriety.
However, 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 - including being fired. One of the most difficult parts for me when I was investigating Lauda was that I couldn't talk about it to anyone (it had quickly become obvious we'd collectively missed something that allowed the T/R to deploy and cause the crash, killing hundreds - and that was not something I easily internalized).
The NTSB did what they said they would do at the beginning of the investigation. I have zero problem with that. To have turned a blind eye to the misbehavior of the pilots unions would have been the NTSB showing bias.
However, 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 - including being fired. One of the most difficult parts for me when I was investigating Lauda was that I couldn't talk about it to anyone (it had quickly become obvious we'd collectively missed something that allowed the T/R to deploy and cause the crash, killing hundreds - and that was not something I easily internalized).
the NTSB wrote that both IPA and UPS took actions prejudicial to the investigation by publicly commenting on and providing their own analysis of the investigation prior to the NTSB's public meeting to determine the probable cause of the accident.
Last edited by tdracer; 26th Aug 2014 at 23:44. Reason: fixed typo
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Similarly, NTSB did NOT revoke their big manufacturer's Party Status after the famous Boeing Scenario was proposed in the summer of 1979.
In that instance the lead investigator may have accepted Boeing's conclusions, but let's not forget that the NTSB summarily rejected Boeing's proposed scenario regarding the 737 rudder hard-over problems.
Not quite, it has stumbled a few times since being granted independence - but overall its record is pretty solid.
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As I said above, the NTSB investigators of UA585 and US427 summarily rejected Boeing's proposal that the B737 rudder hard-over could be caused by inadvertent pedal manipulation by the crews concerned.
(eg, ntsb's Bob S. during the TWA800 investigation deserves recognition for his work)
In the thread-item about mid-way down, notice that the Boeing Submission subtly avoided discussing those failures in the automated features of the Electrical system -- then the NTSB Systems Engineer completely missed those technical problems omitted from the Boeing Submission
Originally Posted by IGh
Recall the basis of the 2-Pilot concept: No Flight Engineer , no 3rd pilot would be needed in the B767 Cockpit (Douglas was working the MD80 development at the same time)
With reference to your talk of certification in that post, remember that as a derivative of the original DC-9 (as with later generations of the B737) the MD-80 is, I believe, given "grandfather" rights from the original 1960's certification regime for the DC-9, and thus is exempt from later regulations strengthening certain aspects of safety and redundancy.
It's also worth bearing in mind that whatever your feelings on the matter, Human Factors is a much better-understood aspect of investigation than it was in 1979.
If you take these factors into account, you can see why the St. Louis MD-80 investigation followed the path that it did - not, in my opinion, because of subtle shenanigans on the part of the manufacturer but because a central aspect of the aviation infrastructure allowing airliners to be given "grandfathered" certification from earlier variants is that the manufacturers' maintenance and operating procedures must be followed precisely, which they were apparently not in this case.
IGh, you totally ignored the primary focus of my post. The pilots unions were excluded from the NTSB investigation because they broke the rules. I find it very hard to believe that these unions were unaware of and hadn't agreed to the non-disclosure rules up front - which means that what they did was knowing and intentional. And that is inexcusable.
It's simple - play by the rules, or be excluded. How can you find fault or accuse the NTSB of bias for following their own rules?
It's simple - play by the rules, or be excluded. How can you find fault or accuse the NTSB of bias for following their own rules?
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tdracer calls our attention to a couple of factors …
… IGh calls our attention to other factors …
… and Dozy directs our attention to other slightly different factor …
…and I fully recognize the accuracy of IGh’s comment that …
..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.
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…
… 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…
…(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…
this verges into a thread-drift away from any UPS mishap…
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.
Sounds like sour grapes to me. Unless UPS and the IPA directly, publicly criticised the NTSB, why on earth would you lock out the two major players? There must be a long history of knives/back stabbing in the USA for such a "keep your public trap shut until we issue the report" rule to be necessary...
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Bloggs:
The NTSB is a political hack government agency at the Board level, and has been for many years. (TWA 841, 1979, investigation controlled by Boeing.)
And, even at the investigator level, it is not what it once was because of "PC" hiring and lack of control.
Sounds like sour grapes to me. Unless UPS and the IPA directly, publicly criticised the NTSB, why on earth would you lock out the two major players? There must be a long history of knives/back stabbing in the USA for such a "keep your public trap shut until we issue the report" rule to be necessary...
And, even at the investigator level, it is not what it once was because of "PC" hiring and lack of control.
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Originally Posted by IGh
Now the USA's "independent" NTSB suffers the consequences of "unreviewable discretion": no obligation to acknowledge past investigative mistakes, nor "retract" mistakes in any Aircraft Accident Report.
That “unreviewable discretion” does not guarantee that the opinions or conclusions are infallible, or that they include ALL the “facts, and only the facts.” As I’ve said previously, humans make up the membership of the “board,” and humans make up the staff. If that human board member or staffer is convinced (based on his/her background, experience, training, and what he/she saw, heard, or learned during the investigation) that what he/she desires to say is factual (whether or not that “fact” is the whole story or merely a part of it) he/she is authorized to say whatever he/she desires to say … and to do so without having someone else “review” that statement and thereby potentially exert some/any influence on that person to modify the statement or, alternatively, prevent it’s publication.
It has always been my impression that having such an unreviewable discretion “guarantee” would, or at least should, allow any participant to feel completely free to reach and disclose whatever conclusion he/she feels is accurate. Anyone who has ever participated on, or even observed, the public hearings held by the NTSB would and should recognize that everyone offering opinions are welcome to do so – regardless of any bias they may be suspicioned to have.
Of course, the board has set policies and agreements under which all participants allowed/invited to participate (either directly on site or through analysis or other review) are knowledgeable of the agreements regarding release of data or conclusions beyond the agreements they’ve each made. Violations of those agreements should logically be expected to incur consequences – from the most menial through removal from further participation … and that shouldn’t come as a surprise.
However, after saying all this, I also think we all need to note that those persons who DO comply with every aspect of all the agreements, and I include both the board members and the staff members themselves, all are human, subject to all the limitations, tendencies, and inclinations which humans are known to have and which are known to have an effect on human perceptions and understandings. To me, at least, this is the limitation we have to recognize if we allow anyone/everyone who participates in such accident/incident reviews to express opinions with “unreviewable discretion.” I am not sure how to better ensure that the conclusions reached are, indeed, the personal, professional, and considered opinions of the specific individual involved – and that of ONLY that specific individual.
Originally Posted by aterpster
The NTSB is a political hack government agency at the Board level, and has been for many years. (TWA 841, 1979, investigation controlled by Boeing.) And, even at the investigator level, it is not what it once was because of "PC" hiring and lack of control.
I’m not sure that anyone, anywhere, could have a more sobering or more seriously clearheaded approach to accident/incident investigation. And, it is my opinion that the quality (including the background and experience levels) of those who have become employed at the NTSB over the years that I have been an active part of the aviation system in the US, has regularly, and substantially, improved
And, for whatever value it may offer, I say all of the above with full recollection of the times where I believe I would have reached a different conclusion … and DID … on more than one occasion.
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@Capt. Bloggs, aterpster:
I think you're being a bit cynical there, to be honest.
In this case I don't think it's a case of politics as much as a case of "once bitten, twice shy".
If you cast your mind back to another 1979 accident - namely AA191 - you may recall that an unprecedented level of media interest and pressure regarding the case caused the NTSB to have their lead investigator hold a press conference which identified a broken engine mounting bolt as the primary causal factor of the accident before their metallurgist had been given a chance to inspect it. Before long, it became apparent that the bolt had fractured on ground contact, which caused the agency considerable public embarrassment when they had to make another announcement that they were wrong.
It's therefore entirely unsurprising that they henceforth put much stricter rules and guidelines in place when it came to releasing information to the public - particularly prematurely.
What we seem to have in this case is the pilots' union making a premature public statement and the airline representative rebutting that statement - which both parties had agreed not to do before the official report was published. The risk of this kind of premature release of information undermining the credibility of the investigation is very real, as AA191 proved, and for better or worse, I believe the NTSB are justified in the sanctions they gave those parties.
I think you're being a bit cynical there, to be honest.
In this case I don't think it's a case of politics as much as a case of "once bitten, twice shy".
If you cast your mind back to another 1979 accident - namely AA191 - you may recall that an unprecedented level of media interest and pressure regarding the case caused the NTSB to have their lead investigator hold a press conference which identified a broken engine mounting bolt as the primary causal factor of the accident before their metallurgist had been given a chance to inspect it. Before long, it became apparent that the bolt had fractured on ground contact, which caused the agency considerable public embarrassment when they had to make another announcement that they were wrong.
It's therefore entirely unsurprising that they henceforth put much stricter rules and guidelines in place when it came to releasing information to the public - particularly prematurely.
What we seem to have in this case is the pilots' union making a premature public statement and the airline representative rebutting that statement - which both parties had agreed not to do before the official report was published. The risk of this kind of premature release of information undermining the credibility of the investigation is very real, as AA191 proved, and for better or worse, I believe the NTSB are justified in the sanctions they gave those parties.
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AA191
DozyWannabe:
It's actually a bit more embarrassing than that.
Ravenswood Airport was right on the NW boundary of ORD, and while it had been closed for some time, there was still a hangar containing parts for light aircraft. The DC-10 ploughed into that old hangar.
The broken bolt was actually a Cessna or Piper part.
And the official who made this bogus pronouncement was Vice Chairman of NTSB, E. T. Driver
...caused the NTSB to have their lead investigator hold a press conference which identified a broken engine mounting bolt as the primary causal factor of the accident before their metallurgist had been given a chance to inspect it. Before long, it became apparent that the bolt had fractured on ground contact, which caused the agency considerable public embarrassment when they had to make another announcement that they were wrong.
Ravenswood Airport was right on the NW boundary of ORD, and while it had been closed for some time, there was still a hangar containing parts for light aircraft. The DC-10 ploughed into that old hangar.
The broken bolt was actually a Cessna or Piper part.
And the official who made this bogus pronouncement was Vice Chairman of NTSB, E. T. Driver
Last edited by barit1; 29th Aug 2014 at 18:15.
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Cheers. 
Another thing that's bothered me about some responses is the snarky-sounding references to political correctness. Desert185's post #174 gives the distinct impression of a belief that if the F/O had been a guy the accident may not have happened. I'm at a bit of a loss as to what aterpster is trying to say about NTSB hiring practices.
Look - the reason large organisations have developed affirmative action processes when it comes to hiring is because it was proven beyond a shadow of a doubt that, left to their own devices, managers of a certain gender and ethnic background were predisposed to hiring candidates of that same gender and ethnic background. Suitability for a job primarily hinges on two things - qualification and experience. Therefore it follows that if managers are predisposed to hiring employees of their own gender and ethnicity, then the end result would be a paucity of experience in candidates of other genders and ethnicities, regardless of qualifications. *That* is why these practices were put in place - to redress the balance in experience.
@barit1: I don't doubt that you're correct in some of what you're saying, but as I understand it, the apparently "sheared" engine mounting bolt was recovered from the runway, not from the hangar. As such, it was unlikely to have come form a Cessna or similar aircraft.
Another thing that's bothered me about some responses is the snarky-sounding references to political correctness. Desert185's post #174 gives the distinct impression of a belief that if the F/O had been a guy the accident may not have happened. I'm at a bit of a loss as to what aterpster is trying to say about NTSB hiring practices.
Look - the reason large organisations have developed affirmative action processes when it comes to hiring is because it was proven beyond a shadow of a doubt that, left to their own devices, managers of a certain gender and ethnic background were predisposed to hiring candidates of that same gender and ethnic background. Suitability for a job primarily hinges on two things - qualification and experience. Therefore it follows that if managers are predisposed to hiring employees of their own gender and ethnicity, then the end result would be a paucity of experience in candidates of other genders and ethnicities, regardless of qualifications. *That* is why these practices were put in place - to redress the balance in experience.
@barit1: I don't doubt that you're correct in some of what you're saying, but as I understand it, the apparently "sheared" engine mounting bolt was recovered from the runway, not from the hangar. As such, it was unlikely to have come form a Cessna or similar aircraft.
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Dozy:
Let me help:
The NTSB has hired some fine female aviation investigators. They are cut from the same cloth as the male investigators of times past; i.e., they had flying in their blood and aviation experience when they hired on at the Board.
In more recent years this pool of qualified female candidates became depleted. So, to fill quotas the Board hired females to be aviation investigators who had zip aviation background. They were given aviation training at government expense.
The product of this program is a range of newer investigators who work from home and often don't even go to the accident site because they don't like either the effort or the gore.
I'm at a bit of a loss as to what aterpster is trying to say about NTSB hiring practices.
The NTSB has hired some fine female aviation investigators. They are cut from the same cloth as the male investigators of times past; i.e., they had flying in their blood and aviation experience when they hired on at the Board.
In more recent years this pool of qualified female candidates became depleted. So, to fill quotas the Board hired females to be aviation investigators who had zip aviation background. They were given aviation training at government expense.
The product of this program is a range of newer investigators who work from home and often don't even go to the accident site because they don't like either the effort or the gore.
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With respect, I'd like to see some supporting evidence for this assertion before I accept it.
One thing I know about the NTSB is that their investigators may be hired from other backgrounds than piloting initially, because they tend to want investigators to be "all-rounders". This is different from the UK AAIB, who tend to hire groups of specialists in certain areas.
I'm certainly aware of many old NTSB hands who've done stellar work without going tin-kicking from the past though, so I'm a little sceptical that this is in fact an issue.
One thing I know about the NTSB is that their investigators may be hired from other backgrounds than piloting initially, because they tend to want investigators to be "all-rounders". This is different from the UK AAIB, who tend to hire groups of specialists in certain areas.
I'm certainly aware of many old NTSB hands who've done stellar work without going tin-kicking from the past though, so I'm a little sceptical that this is in fact an issue.
Last edited by DozyWannabe; 29th Aug 2014 at 22:35.
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Desert185's post #174 gives the distinct impression of a belief that if the F/O had been a guy the accident may not have happened.
Using gender-based hiring quotas would be illegal in the U.S. Federal government. I can't prove it's never happened, but if it were widespread, it would be almost certain to come out. But there are plenty of other problems with the Federal hiring process.