Reason: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17
1. FAA's PRIOR TESTS
OF WIRE INSULATION FAILURES, APPEAR LITTLE KNOWN, TO PILOTS,
INSPECTORS AND MAINTENANCE MECHANICS .
The NTSB's Final Report's focus on a mechanical fault is
inconsistent with the FAA's knowledge of electrical
wiring insulation failures . Three FAA Tech Center
reports of wire insulation construction faults and resultant failures
(arc-tracking, ticking faults) appear largely unavailable to any but
those who have specific knowledge of their content. Contained in
these three reports were observations of self-igniting, self-fueling
wire insulation fires of 2,000 degrees(F.), excessive smoke
generation, warnings about resetting tripped circuit breakers and the
critical message that these were not mechanical faults (chaffing) but
rather a "electrical" failure of the wire insulation. The 1995 report
specifically said; "This testing was conducted to evaluate the
FIRE POTENTIAL that may result from
ELECTRICAL faults".
Not until just this spring were the author's (Patricia Cahill) works
("Aircraft Electrical Wet-Wire Arc Tracking", 1988, DOT/FAA/CT-88/4;
and "Flammability, Smoke, and Dry Arc Tracking Tests", 1989,
DOT/FAA/CT-89/21; and "Electrical Short Circuit and Current Overload
Tests on Aircraft Wiring", 1995, DOT/FAA/TN-94/55) included in the
New Jersey Tech Center's Library Database at
<http://www.tc.faa.gov/its/worldpac/ENG/wphome.htm> This
occurred after our complaints to the NTSB over a period of almost 1
year of FOIA requests.
None of the report numbers or 'keywords' ("short circuit, ticking
fault, current overload, wet or dry wire tracking, wire insulation,
carbonization, smoke test, electrical wire insulation, sixty-degree
flammability tests") work in the NTSB or FAA database search engines
at:
http://nasdac.faa.gov/asp/fw_/Crosssys.asp
(New URL) or
http://www.ntsb.gov/aviation/months.htm
Virtually none of the 'keyword' commercial aircraft types names
("DC-9, MD-80, Boeing 747, etc.) worked in these same search engines.
Only about 11% of the 264 such commercial in-flight electrically
related fires or smoke events testified to by FAA's Thomas McSweeny
during Senate Aviation hearing (#103-397, 1993). Our laborious
line-by-line search of over 1,000 items turned up but 35 such
commercial emergencies. Neither the three specific fires found in
that FAA 1995 Tech Center Report were found, nor were two specific
media reported fires.
With that 1995 Tech Center report in-hand, a FOIA request was filed
to the same authoring (N.J.) Regional that wrote that Report. As a
test, the exact date was omitted and only the question for such
"studies/reports since 1990" was made. The results demonstrated a
lack of knowledge or worse.
a. FAA N.J. Tech Center response on 1/14/ deflected the 1/6/97 FOIA
request for "studies/reports since 1990" to Washington.
b. FAA N.W. Regional response on 4/15/97 claimed nothing "within the
scope since 1990", but supplied Cahill's 1988 report. The N.W.
Regional had authored many electrical related Airworthiness
Directives and Bulletins but appeared ill informed to the other two
FAA Tech Center reports.
c. Another FAA N.J. Tech Center response on 5/16/97 claimed; "all the
reports associated with your request that have been prepared at the
Tech Center" are now provided with another Cahill Report dated 1989.
Still omitted was that 1995 Report, a report far more detailed of
electrical insulation failures.
d. Finally on 11/24/97, FAA's N.J. Tech Center again responded to
another request with that elusive 1995 Report, but then said; "This
is the only report on the subject prepared at the William J. Hughes
Tech Center". Contrary to that, all three reports are clearly marked
as being generated at this N.J. Regional.
2. OTHER IN-FLIGHT
ELECTRICAL'S - VERSUS THE O2 CANISTER THEORY
WERE IGNORED.
The NTSB Final Report's focus on 6
prior oxygen canister related fires. They ignored the fact of the 35
reports of electrical wire related in-flight fires in all aircraft
types we had found. By the FAA's Senate testimony alone, there may be
as many as 264 . Our search included such
aircraft types as Boeing 707s, 737s, 747s, Douglas DC-3s, DC-8s,
DC-10s and MD-80 series aircraft. Of great concern to us is, that of
the random 35 found in the databases above,
DC-9s held a disproportionate share of 10 .
When the electrically similar (so much so, that both aircraft types
were combined in FAA Bulletins and Directives) MD-80s series aircraft
were included, that raised these similar type aircraft share to 14
(or 40% of the random sample). Again, this
is still far short of the 264 referenced to by FAA's Thomas McSweeney
in that 1993 Senate Aviation Committee report (#103-397).
The NTSB second guesses the VALUJET pilot. They said, "No
electrical problems! "
There is the CVR recording of ONE LIVE
WITNESS . The Captain reported, 'within
12 seconds', "WE HAVE AN ELECTRICAL PROBLEM. . . .
. " To fit the NTSB's theory that 02 canisters
caused the crash, this witness statement had to be
deleted and given no weight in
their Final Report. The NTSB, once they had predetermined that '02
canisters had caused the accident, then all evidence; witness
reports; technical data and scientific facts MUST
fit their theory ! This is called Malfeasance,
Misconduct, Criminality!
Read on and see how the NTSB builds their story and
NTSB's NOSE continues to grow!
3. THE REPORT
DELETED ALL EYEWITNESS ACCOUNTS --
TO A CONTROLLED DESCENT.
The Report's claim to a 'uncontrolled decent to impact' was
directly contradicted by these consistent accounts of level flight
above the Everglades by 6 of the 7 eyewitnesses in the "Witnesses
Group Chairman's Factual Report." (The 7th saw only the impact). On
page 4 of the Report, the "Statements of Witnesses" is brief with
only 4 of the 7 witness's accounts being carried into this Report.
Here, in describing the crash this Report said:
"Two witnesses fishing from a boat in the Everglades when flight 592
crashed stated that they saw a low-flying airplane in a steep right
bank. According to these witnesses, as the right bank increased, the
nose of the aircraft dropped and continued downward. The airplane
struck the ground in a nearly vertical attitude.
"Two other witnesses who were sightseeing in a private airplane in
the area at the time of the accident provided similar accounts of the
accident."
Of these four, the one account from the private aircraft is
falsely attributed . The ten
pages of 7 eyewitness accounts from the "Witnesses
Group Chairman's Factual Report" had been reduced to just
two paragraphs .
Portions of the 6 eyewitness accounts and testimony of level and
controlled flight above the terrain were
omitted . Two eyewitness testimonies were edited to
include only that portion of their testimony that described the
nearly vertical impact during the final seconds.
Of these four included in the Report, one (Mr. Delisle) did not see
the aircraft flying but only the impact ( "never observed an
airplane, but he observed the explosion cloud it made.")
None-the-less, his (Mr. Delisle's) statement was falsely
claimed to be the same as the other three statements
edited to include only that portion to only a dive and nose-in
impact.
In review, every one of the 6 witnesses accounts to the aircraft
Flying-Level and In-Control, were deleted
in this Final Report. Deleted from the
Report were the witness accounts of;
1. Steven Almecia Sr. and Steven Jr. ; "Flying past at a very low altitude in a right turn". (2 witnesses)
2. Walton Little, Jr.; "It continued toward the canal in a nose level attitude ..". "The nose was still level"
3. Henry Nelson; "was banking at an 80 degree angle and appeared to be normal with the exception that it was flying at a low elevation."
4. Chris Osceola; "It was in a horizontal position and, as it approached the canal ".
5. Daniel B. Muelhaupt; "It appeared to be at his altitude, descending in a 75-80 degree left bank".
A most important factor in any other investigative process, but here witness accounts in the area of flight below the radar's reach were deleted or altered to fit a 'plunge scenario'. And thus the reader is left with the clear picture of a helpless plunge to the ground because of the calamitous fire and a loss of control initiated by overly hot 02 canisters promoting a fast moving fire. In this contradictory report , the witness deletions are but one of many things wrong with this Final Report and why there are real reasons why the NTSB and any reader should be uncomfortable with it.
4. THE REPORT'S CARGO
FIRE CLAIM, CONTRADICTS ACTION TAKEN
BY THE CREW.
The Report summed up the crash: They claimed a cargo hold and
then a resultant cabin
floor fire. From the critical 'Analysis' on page 103 (para 1), it
said;
"All of these factors in combination most likely prevented, any
noticeable migration of smoke from the forward cargo compartment into
the passenger cabin or cockpit, until relatively late in the
development of the fire." On page 134, item 13, of the "Conclusion"
in this Report, it said:
"Only a small amount of smoke entered the
cockpit before the last recorded flight crew verbalization at 14:38,
including the period when the cockpit door was
open ."
The Report's claim to a fire initiated in the forward cargo bay and
then the CABIN, omitted an explanation of
the cockpit voice recorders capture of a "loud rushing
sound ", a sound explained when the crew exercised the
DC-9s emergency procedure for excess COCKPIT smoke
opening the cockpit slider windows .
According to the Report's page 174 account and transcript of the
cockpit voice recorder (CVR), this sound
began at 1411-21 (2:11PM and 21 seconds) and
continued until the last taped recording at
1413-11. For 1 minute and 50 seconds this sound continued. Although
every chime, click or other sound was given an explanation, none was
given for this continuing "loud rushing
sound ". On page 50 of the Report, it appears that the
explanation was given in another way and few would make the
connection, it said:
"The Douglas smoke removal procedures were developed as a result of
DC-9 flight tests conducted in 1975 by the Douglas Aircraft Company.
The flight test also revealed that opening a cockpit
window would effectively remove cockpit smoke if the
smoke originated in the area of the cockpit." However, when faced
with a CABIN fire, a crew caution was given
to NOT open the cockpit slider windows.
From this Douglas test, it said; "However, in tests with
smoke created in the cabin or with the
cockpit door louvers open, smoke was drawn into the cockpit as soon
as the cockpit window was opened". (This means that the
smoke was coming from the cockpit)
That "loud rushing sound" on the CVR need not have
gone long unexplained. Opening cockpit windows for Cockpit Smoke is
standard operating procedure in any aircraft type. Opening the slider
windows on any DC-9 and comparing the CVR recording of it, would have
quickly solved this 'mystery'. The crew's actions
provided positive audio evidence to smoke
in the cockpit for almost two minutes before the last communication,
but it too was ignored in this Final
Report. Although early cockpit smoke was consistent with the
many other reports of electrically
related in-flight fires , it was contrary to the
NTSB claim of a cargo-ignited fire.
5. THE REPORT
REMOVED MORE
EVIDENCE TO COCKPIT SMOKE AND
FIRE.
On page 46 of the Final Report, the NTSB claimed that; "No evidence
of soot or fire damage was found on the recovered electric and
electronics compartment components and structure located just under
the cockpit and forward of the cargo compartment".
Contrary to that was the contrary contemporaneous evidence released
to the press and publicized immediately following the accident.
Examples include;
a. U.S. News, web posted 11:55 p.m. May 15,1996; "A oxygen bottle in the cockpit had soot on it."
b. A.P Wire, Miami, May 15, 8:54 p.m.; "Recovery workers pulled more soot-stained wreckage from the Everglades and investigators were examining a scorched stairway beneath the cockpit for clues to a possible explosion or fire aboard Valujet Flight 592."
c. Washington Post, May 16, page A8; "Soot-covered or scorched parts found so far seemed to form an arc from the front of a circuit breaker panel in the ceiling above the forward lavatory down to maintenance steps that are below the cockpit and near the main equipment center."
d. AW&ST, May 20, 1996, page 24; "They already have recovered parts from the electronics equipment bay, cockpit and forward cabin that are covered with soot and show signs of exposure to high temperatures ."
6. THE NTSB DID
NOT PERFORM CANISTER FIRE TESTS! THEY ADOPTED FAA's
CANISTER TEST AS THEIR OWN.
On page 102, and with the words, "In the Safety Board's
fire tests ", the NTSB Final Report critical "Analysis" section
implies that the NTSB performed these fire
tests. Certainly a minimal and objective investigative step since the
NTSB was also assigning the FAA as a casual factor to the accident
for not properly responding to prior oxygen canister related fires
and inadequate oversight of ValuJet's maintenance. On April 6,1998 a
FOIA response (control # 1998-005131CT) from the FAA New Jersey Tech
Center disclosed the following:
Start Quote: "Regarding the second part of your request for records
relevant to the Valujet 592 flight, at the
request of the National Transportation Safety Board,
the FAA Technical Center conducted 3 full-scale tests related to the
in-flight fire accident of May 1996. In a strict sense, the tests
did not simulate a Class D cargo
compartment. Since the cargo door was left
open to facilitate video/photographic coverage, and the size (volume)
of the test was far greater than the cargo compartment in the
accident aircraft, and what is allowed by regulation for Class D
compartments. Therefore, it is difficult to relate the
test measurements to the conditions that might have
existed inside a closed, small Class D cargo compartment.
Enclosures
Enclosure 1 - Oxygen Generator Testing: This is a description of the
fire load for each test. Note that in tests 1 and 3 a sustained fire
did not occur. Also, under test 5 there were 2 attempts that did not
result in a sustained fire. Enclosure - 2. Temperature, heat flux,
and gas profiles for tests 2, 4, and 5. Enclosure - 3. A video of the
above-mentioned tests 2, 4, and 5.
Finally, a report has been drafted which describes preliminary tests
with single canisters and multiple canisters packed in a cardboard
box that were conducted in an open area .
That report has not been finalized nor
reviewed prior to publication. It will be
available in approximately 3 months."
That August 19, 1997 NTSB Final Report said the canisters started
that fire. But, 8 months later, and as of April 6, 1998, the FAA had
NOT released even a Draft Report of Preliminary Tests "with single
canisters and multiple canisters packed in a cardboard box that were
conducted in a open area." The 'tests' even came with its own
disclaimer: "Therefore, it is difficult to relate the
test measurements " There was
NO Draft/Final Report, No Final Conclusions
and, further on, certain other test results were also
left out (measurements of the activated
canister exterior temperatures , tests to
"jostle" the un-safety triggering mechanisms to actuate).
In five firings of these canisters, the 1st and the 3rd did
not result in sustained fire. In the fifth,
two attempts failed. Three out of five failures is hardly a
consensus. Because of lack of detail, it was not said if the one
failure mode seen in the Report's 7 Incidents of canisters fires was
adopted here, again, to assure a sustained fire. (We note that in the
simulated TWA 800 Center Wing Tank test for a jet-fuel explosion, a
mixture of propane and hydrogen was
used ). On page 94 of the Report, incident # 2, from Eastern
flight 215 was detailed. Here, this canister incident used in the
Report concluded with;
"INCIDENT # 2:" "The Safety Board found that the chemical generator had been activated; however, placing the generator on the cart after it was activated, caused a full or partial block of the oxygen outlet tube, which resulted in a pneumatic over pressure failure of the generator. The exposed oxidizer continued to burn and produce oxygen creating an oxygen-rich environment resulting in the ignition of the linen napkin and other material in the galley."
In a production more worthy for a TV movie, than a accident
investigation, that July 1996 video of a raging fire, in a many times
larger DC-10 cargo compartment, and left open for camera purposes,
was released. Worst yet, the FAA says here, that in these "tests"
the activating pins had to be pulled .
Whereas on flight 592, the presumption was made that they were
'jostled ' out. Yet no FAA or
NTSB tests were conducted to test this theory . An
independent lab (Inalab Inc.) tried, but could not !
7. THE REPORT'S CLAIM
TO "JOSTLED" CANISTERS WAS NOT
TESTED .
From page 102 of that critical 'Analysis' section comes this
statement: "Activation of a generator would have been most likely to
occur during an event that could cause movement or jostling of the
contents of the boxes."
A critical point ; IF-jostling did occur,
IF- the canister/s did activate, IF-the canister got hot enough to
auto-ignite bubble wrap, IF-elevated oxygen levels lowered AIT
temperatures. No tests were found where the NTSB or the FAA performed
any tests to weigh the NTSB's claim that 'jostling' somehow set off
one or more shipped oxygen canisters. In the Board's 'Tests'
(actually FAA's ) at the FAA N.J. Tech
Center, the firing pins had to be pulled .
That independent lab (Inalab) tried, but failed. That lab's statement
follows;
"The experiment "Kessler 4" was conducted to assay the mechanical
integrity of the oxygen generating canisters. A single canister was
held at an approximate 6 foot height and
dropped to the floor. It was dropped four
times , each time positioned on a different axis prior
to release and subsequent impact. This experiment was conducted to
simulate substantial mechanical abuse
(occurring during takeoff and or landing on a aircraft) and its
potential for activation of the units. Both ends were severely bent
and damaged after the repetitive 6 foot falls and subsequent impact,
but in NO instance was the generator
activated ."
We consider the NTSB's silence to several parties' questions
about this lab's findings a tacit admission that they do not
dispute this lab's findings.
8. THE REPORT CLAIMS
HEIGHTENED OXYGEN LEVELS -WERE
UNSUPPORTED .
On page 54 (footnote 75) The Report claimed: "
Auto-ignition of the bubble wrap in contact
with the hot surface of the generators, in the presence of elevated
concentrations of oxygen, was the source of ignition."
Beyond "Incident # 2" (blocked outlet tube) in Item 6 above, nothing
to support this 'elevated oxygen levels' promoting auto-ignition was
found in the NTSB files. From 'Board's Tests' in item 6, above,
"Enclosure 2. Temperature, heat flux, and gas profiles for tests 2,
4, and 5" included the "Oxygen Profiles" chart ("Run Date 11-06-1996,
Run # 2") of oxygen levels taken during those FAA N.J. Tech Center
tests -the oxygen levels are flat .
In published industry data, including the three editions of
"Combustion" by Professor Irving Glassman, Academic Press),
no support to heightened oxygen levels
lowering AITs was found.
That Hawaiian State certified arson lab., Inalab Inc., addressed this
when it said: "An important, industry wide
misconception is that oxygen, in of itself, effects
the 'ignition temperature" of solid or liquid fuels. The presence of
oxygen is a necessary and limiting condition for combustion. However
oxygen DOES NOT in an of itself, make a
fuel more susceptible to ignition, nor does it
"lower " a material's fundamental ignition
temperature."
Again, it appears unsupportive opinion has
been substituted for scientific fact. Several parties have brought
this critical point to the attention of the NTSB. We consider the
NTSB's silence a tacit agreement to the Inalab statement.
9. THE REPORT SELECTED
TEST DATA TO SHOW HIGHER O2 CANISTER
TEMPERATURES
Key to the NTSB conclusion, that one
or more activated oxygen canisters initiated that fire is,
'How hot does the exterior of an activated canister
get'? Although the NTSB quickly adopted and promoted the
FAA's horrifying fire video, the NTSB also continued to use a
higher operating temperature from the
manufacture product data. Admittedly conservative said one
manufacturer: these numbers were meant to protect the manufacturer.
From page 7 of the Final Report it said, "Manufacturing test data
indicate that when operated during tests, maximum shell temperatures
typically reach 450 to 500 degrees F. Another FOIA response
(#1998-002827) from the FAA Tech Center showed a far lower
number.
The FAA said: "There were several attempts to measure the surface
temperature of an activated canister. The most reliable
data was obtained with a thermocouple spot welded to
the steel canister. During this test, the maximum temperature was
400 degrees Fahrenheit, which occurred at
about 10 minutes."
Nothing more is seen in the Report to
reconcile this difference. The NTSB claim that this 500 degree
temperature was sufficient to auto-ignite (auto-ignition or AIT)
bubble wrap or cardboard came with NO supportive
data . Such appears to be unsupported
opinion and appears contrary to fact in other
scientific ways. In published tests by a state of Hawaii certified
arson lab (Inalab Inc.) AIT temps began well
above 500 degrees (550). This 20-year arson lab further
stated that, in three tests, including a heavily wrapped canister,
the exterior temperatures reached no more than
404 F.
People understand that 400 degrees does well for pizza but is not a
threat . To go further, John King, a licensed FAA
inspector, (lic. A&P#1552888), placed bubble wrap in a calibrated
commercial oven and noted that typical bubble wrap packing did not
ignite until over 550 degrees . If you
don't mind the goo, try this 400 degree temperature, in your home
oven.
10. THE REPORT'S CLAIM
TO A CAUSE OF A CRITICAL FLIGHT DATA
RECORDING IS
IMPOSSIBLE.
On page 101, the Analysis of the "Propagation and Detection of
Fire" section, the NTSB demonstrates a appalling lack of
understanding of the most elementary systems in pressurized
commercial aircraft the pitot/static system. The NTSB claimed that a
wheel/tire assembly "ruptured" due to the cargo fire, and
that this pressure was then sensed in the flight data recorder via
the alternate static sense line". Here it said: "The first
indication of a problem" during the accident flight occurred at
1410:03, approximately 6 minutes after flight 592 took off from
Miami, when the CVR (cockpit voice recorder) recorded an unidentified
sound, which prompted the captain to ask "What was that?
"Simultaneously, an anomaly in the FDR altitude and airspeed
parameters occurred consistent with a static pressure increase of
about 69 psi.. Within 12 seconds, thecaptain
reported an electrical problem, and at 1410:25, there
were voices shouting "fire, fire, fire in the passenger cabin."
" In the Safety Board's fire tests , a main
tire that had been inflated to 50 psi ruptured 16 minutes after the
first oxygen generator was activated, when the fire destroyed 9 of
the 12 tire side wall plies. Because the tires in the accident
airplane were loaded just forward of the cargo door, the tires would
have been located just above the static ports. The FDR altitude and
speed data are based on readings from the left alternate static port.
It is located on the left side of the fuselage at FS 341 between
longerons 26 and 27, indicating that the unidentified sound on the
CVR and the FDR anomaly at 1410:03 were most likely caused by
the rupture of an inflated tire in the forward
cargo hold compartment. The tire was partially burned through by the
fire. Based on this sequence of events, the investigation analyzed
when the fire on board the accident flight might have been
initiated."
This was impossible. As a matter of proper function, all pressurized
aircraft pitot and static system lines are
isolated from any internal aircraft
pressures and are expressly plumbed to the exterior of
the aircraft . These systems are designed
to sense outside pressures only. No claim was made in
the Report that the static lines were burned through or compromised
internally.
11. THE REPORT'S CLAIM
TO THAT "RUPTURE" IS CONTRARY
TO FACT AND PRACTICE.
Key to the Report's claim that the shipped tire
assembly (two assembled wheel halves with tire mounted and inflated)
"ruptured " was the implication put forth,
that it was a serviceable (new ) unit. The
Report continued with this 'new' tire scenario on page 44 when it
said: "The edges of the tire along this tear were deflected outward,
consistent with the tire having ruptured along this tear in the side
wall." Further on, the Report continued on page 55 with: " In the
fire test, two boxes of oxygen generators were placed on top of a
main gear tire inflated pressurized to 50 psi."
Like the impossible tire "rupture sensed in the alternate static
sense line" above in Item 10, this appears to demonstrate two other
appalling lack of understanding of basic aviation industry practices
and wheel safety features. First, the 'rupture' only works if
the tire had any pressures . There were
none . Because of past industry accidents where these
aluminum wheel halves had developed hard-to-see in-service cracks,
these wheels have exploded to maim and kill. The pressures of these
tires are always dumped before removal .
Simply, and like automotive tires, the tire fill valve is
removed and discarded . Secondly, all outer wheel
halves are equipped with 'fuse plugs'. Each plug is approximately as
big as your thumb, and has a small hole through it that is packed
with a material that melts long before improperly working braking
systems heat up the wheel assembly. It's a matter of a few hundred
degrees before pressure is released and way short of the 2 to 3,000
degree fires mentioned in this Report. Another FOIA request
was made to clear up the tire removal status . The NTSB's
FOIA response to John D. King of May 27, 1998 and signed by Jim Hall
said:
" The Safety Board's investigation found that the wheel
assembly was a removed unit."
An unserviceable (used) tire is empty .
Tires are not swapped (with other aircraft) but
simply removed for wear or damage beyond limits. Here, this specific
tire was noted in this
Report as having "X" shaped tears and cuts. In the view of this
writer, who has performed
hundreds of such tire changes, worn tires is the chief reason for
tire removals; such 'tears and
cuts' is the second. I have never seen a 'ruptured
tire ' due to heat, but I have changed
many with "X" shaped tears and cuts due to sharp objects.
12. THE REPORT'S TIRE
CLAIM SHOULD HAVE CREATED AVIATION HISTORY.
The Report's tire claim missed credit for recognizing
a point of aviation history - the first on-board DC-9 fire
suppression system had failed. On page 133 of the Report, item 8, it
said:
"If the plane had been equipped with a fire suppression system, it
might suppressed the spread of the fireÖ. It would have delayed
the fireÖ. It would likely have provided time to land the plane
safely." Industry wide practice for aircraft tire fills is
not air - but nitrogen , the same nitrogen
proposed to inert the 747 center wing tanks against possible
explosions, like that of TWA 800. The Report made only
unsupported claims of discharging oxygen
canisters and increased oxygen levels but said nothing of the effects
and fire inert release of nitrogen because of that tire
"rupture".
13. THE REPORT'S
ACCOUNT OF TROUBLED SHIPPED PARTS - THE WRONG
DAY?
In another leap of faith, we try to understand how those shipped
oxygen canisters and that tire, soon to "rupture" in that fire on May
11th, arrived in ValuJet's Atlanta Stores on May
10th ? From page 176 of the Final Report, that critical
shipping document is displayed. The "SaberTech shipping ticket, No.
01041" is clearly marked on the bottom "Rec'd. At Valujet Airlines
(ATL), Date 5/10/96, By Christopher."
14. MORE TROUBLE WITH
THAT SHIPPING TICKET WRONG SERIAL NOs.
Again, from page 176 of this Report and on that SaberTech shipping
ticket, No. 01041, it says of item 4 (the main wheel assembly) that
the serial number was (illegible) "R 236".
Contrary to that, and from the originating "NTSB Fire and Explosion
Group Factual Report, pages 2 and 3, D. Details of Investigation, 10
Tires (2nd paragraph)." "Another gear tire (Goodyear part number
404F42-9). S/N 435403071 was mounted on a wheel assembly (part #
9561146CI B assembly 9544451. SN OCT 73 -11893) on inboard and
outboard assemblies)."
None of the above various numbers fit. Industry practice is to use
the inboard and outboard wheel assembly numbers. Here, that would be
the "Oct73" (year of manufacture) and "11893" (assigned serial
numbers). The NTSB's claimed shipping ticket (above in Item 13) for
the boarded wheel/tire assembly said to have "ruptured," lists a
different serial number ( ? R286). This is different than
that in the originating fire and explosion report.
15. THE REPORT
DISREGARDED EVIDENCE TO A DANGEROUS
ELECTRICAL CONDITION
.
From page 36 of the report ("Maintenance"), unexplained and
unrepaired electrical malfunctions were listed. The left fuel gage,
cockpit inter-phone, auto-pilot malfunctions items were continued as
the fixes remained elusive . A more serious
electrical item, the right auxiliary hydraulic pump, was added and
now prohibited that final flight from Miami. This grounding item was
cleared and here the Report said: "After examining the pump, cleaning
the cannon plug pins, and reconnecting the cannon plug, a mechanic
was able to reset the circuit breaker without further difficulty."
In the trade, this is called "pencil whipping" an item (a bogus
action, having no real action to correct the problem). From the
Report's critical Analysis section (ref pg. 100) it further
said: "There was no evidence of preexisting mechanical
malfunctions or other discrepancies in the airplane structure, flight
control systems, or power plants that would have contributed to the
accident."
Contrary to that, the FAA knew far more. With an
anonymous call to the FAA after the crash,
a Valujet mechanic admitted so to Jim Cole of the
FAA . This 7 page admission that circuit
breakers had been "by-passed " (hot wired
) and a number of electrical
troubles were seen became the NTSB's evidence item 6E -
but remained buried in the NTSB's index
(NTSB File DCA96MA054) of 4,750 pages under "Survival Factors 6
Exhibit No. 6G Anonymous Interview". 'Bypassing' or
hot-wiring a circuit breaker removes the circuit
breaker from the circuit leaving that circuit with
no protection against direct short
circuits or the electrical wire insulation faults described in those
FAA N.J. Tech Center Reports .
Reflecting back to those FAA Tech Center Reports, and again, in this
1995 Report, gave grave warnings regarding the role of
circuit breakers when it said: "Abstract: This document
describes the electrical short circuit and current overload tests
that were conducted on wires used in commercial transport category
aircraft. This testing was conducted to evaluate the fire potential
that may result from electrical faults. Results of this testing
showed that circuit breakers provide reliable over-current protection
and that circuit breakers may not protect
wire from ticking faults (an intermittent metal-to-metal
conductor-to-conductor, conductor-to-structure, etc. that results in
the discharge of sparks and arcing events) but can protect wire from
direct shorts. It also showed that circuit breakers may not safeguard
against the ignition of flammable materials by ticking faults."
"Current overload testing that resulted in complete thermal
degradation of the wire was also conducted to compare it with a
fire-exposed wire. No differences were seen; however, the conductor
of the wire subjected to the fire was more brittle than the current
overloaded wire. Further testing along with metallurgical evaluation
would be necessary to substantiate this finding fully."
This Valujet mechanic's unprecedented admissions remained hidden and
cataloged under 'Item No. 37'; one of 137 items, while over 106 items
relating to 'Hazardous materials' filled the report. The anonymous
caller need not have remained anonymous. Because a simple record
search of his other admitted actions, would have directly led to his
earlier required maintenance signoffs. His admissions and any of the
relevant portions of that 1995 FAA Tech Center Report
(DOT/FAA/CT-TN94/550) were not mentioned in the NTSB's Report.
16. NO TESTING WAS
DONE TO DETERMINE IF WIRE INSULATION STARTED THIS
FIRE.
The Report indicates no effort was made beyond an ineffective visual
inspection to consider the wire insulation as the initial fuel for
this in-flight fire. The Report's 'Analysis' section, page 100, said:
Para. 4 "The airplane's electrical system was examined for
indications as to what caused the electrical problems initially noted
by the flight crew. However, because so much of the wiring ran
adjacent to the cargo compartment, and because so many of those wires
were severely damaged, the source of those electrical anomalies could
not be isolated." Para. 5 "Examination of the
heat-damaged wire bundles and cables revealed no physical evidence of
short circuits or of burning that could have initiated the fire."
Evidence to the visual inspections only comes from two points.
Reference is made to the NTSB's FOIA response # 97-442 on 12/23/97,
to Mr. Ernest Hadley whereas one fundamental (soot) test
was not done . In Mr. Hadley's letter, the NTSB stated:
"There was no testing done of soot samples." No other explanation was
given. Worst yet, the metallurgical testing suggested by the FAA was
also not done. In the FAA Tech Center (Cahill) 1995 Report it said in
the "Abstract": "Current overload testing that resulted in complete
thermal degradation of the wire was also conducted to compare it with
a fire-exposed wire. No differences were seen; however, the conductor
of the wire subjected to the fire was more brittle than the current
overloaded wire. Further testing along with metallurgical evaluation
would be necessary to substantiate this finding fully."
No such recommended metallurgical testing appeared in this
Report.
17. THE REPORT
PROMULGATED MANY UNSUPPORTED SCENARIOS REGARDING SYSTEM FAILURES AS
MECHANICAL RATHER THAN ELECTRICAL .
Like Swissair flight 111, the Valujet Flight Data Recorder and
Cockpit Voice Recorders underwent abnormalities and power losses.
This Report focused only on the presumed effects of wire, being burnt
by surrounding fuels, rather than the wire insulation itself
being the fuel as seen in the FAA Tech Center
reports. Here, on page 101 (ref para 5) of the 'Analysis' section it
said, "Further, the heat and fire damage to the interior of the cargo
compartment was more severe than the damage to the exterior,
consistent with the fire having been initiated inside the cargo
compartment. Finally, the heat-damaged wire bundles were not routed
near the breached area of the cargo compartment, whereas the boxes
containing the oxygen generators were loaded into the area directly
beneath the breached area of the cargo compartment. Thus, the
electrical system was not a source of ignition of the fire."
From this assumption, crew action (rather than electrical insulation)
explanations were assigned to the following abnormalities in this
Report's, 'Analysis' section (page 106) Ref para 3;
a. "According to FDR data, while the left engine remained at its previous EPR setting, the right engine's EPR decreased to the flight idle value. The reduction in thrust would likely have been an intentional act by the flight crew to reduce power for the descent to return to the ground."
b. "The activation of the landing gear warning horn at 1410:28 suggests that the flight crew had reduced power to idle (the warning horn is activated by one or both throttle levers being positioned at approximately the flight idle position). Because the flight crew would not have intentionally reduced thrust on one engine only, they must have been unable to reduce the thrust on the left engine because of fire damage to the engine control cable located above the compartment.."
Ref para 4
c. "Further, the thrust asymmetry continued throughout the period and resulted in a side slip and lateral accelerations that were not corrected with rudder application. Therefore, left wing-down (LWD) aileron deflections would have been necessary to keep the airplane from rolling to the right."
d. "Because there were no right roll indications in the FDR heading data, the flight crew must have been applying the LWD control inputs."
Ref para 5
e. "The FDR indicates that at 1411:20, vertical acceleration increased to about 1.4 G, although the control column had not moved. Subsequently, the control column position was moved forward about 5 degrees to reduce the vertical acceleration back to 1 G. At this time, the airplane leveled temporarily at about 9,500 feet. These events indicate that the flight crew was confronted with a disruption in pitch control (in the elevator or trim systems), and was active in maintaining at least partial control of the airplane. The pilots could have found the disruption in control to be distracting, and the level off is consistent with their attempts to handle the pitch controls carefully. The development of malfunctions from the electrical system to engine thrust controls and flight controls indicates that the flight experienced a progressive degradation in the airplane's structural integrity and flight controls.
Ref page 107, para 3
f. "The control inputs required to balance asymmetric thrust during the steep left turn, followed by the level-off, indicates that the flight crew initiated a turn and descent. And the captain and/or the first officer were conscious and applying control inputs to stop the steep left turn and descent (until near 1413:34). Thus, the airplane remained under at least partial control by the flight crew for about 3 minutes and 9 seconds after 1410:25.
THIS REPORT IS, AGAIN, INCONSISTENT
WITH THE FAA's KNOWLEDGE OF WIRE INSULATION
PROBLEMS.
Contrary to the Board's rejection of any wire related cause to
the Valujet 592 crash and claims that there was no evidence, the FAA
and the NTSB take a different stance on TWA 800. In the FAA's latest
round of directives to increase wire insulation inspections, Boeing
had vigorously opposed them as any claim to the reason to the loss of
TWA 800. Part of the objection was the lack of proof.
The FAA claims that prior electrical troubles were an indicator of
impending greater problems. On October 6th, in a Newsday TWA 800
article by staff writer Sylvia Adcock, this FAA response was
included: "The wires to the fuel-measuring system on 747s run from
the cockpit to the center fuel tank. They carry an extremely low
current, too small to spark an explosion. But investigators have
determined that it's possible for more electricity to get into the
wires, either from damaged wiring in the same bundle or
electromagnetic interference." "The wiring theory is one that Flight
800 investigators have focused on, although it's doubtful that the
scenario can be prove. Boeing vigorously opposed the rule, filing
documents with the FAA stating that there was no conclusive evidence
that the TWA explosion off Long Island was caused by a failure of the
fuel-measuring system. The FAA said it agreed that evidence is not
conclusive, but it noted that proof is often
destroyed and that low-level electrical
arcing from one wire to another often leaves no
trail."
"Boeing also told the agency that if a wire bundle to the
fuel-measuring system failed, the problem would show up on the fuel
gauge and would be caught before it caused an explosion. Here again,
the FAA disagreed, noting that two minutes before the explosion on
Flight 800, the flight crew noticed erratic readings on a fuel-flow
indicator, which is wired in the same bundle as the fuel-measuring
system. "Such indications could have been due to a failure in the
wire bundle," the FAA said."
Failures in wire bundles abounded in high current and high voltage
generator feed wires that arced to adjacent structure or wires and
was evident in those 37 in-flight fire list we compiled from the
databases. From those FAA or NTSB files, the importance of shutting
off the generator feeds in previous accidents was noted. For
example;
a. 2/2/1989 - Douglas DC-9 (SAS) "A fire developed in the circuit
breaker panel and the cockpit filled with thick black smoke. The crew
isolated the source of the electrical energy by switching off both
electrical generators".
b. 1/18/1990, "US Air MD-80 was forced to return when the cockpit
filled with smoke. Left generator tripped off-line and the captain
turned the right generator off. When starting the auxiliary power
unit, the smoke returned. The smoke disappeared again when only
emergency power was left on".
c. 7/5/97, DC-9-30, Northwest Airlines. NTSB Identification:
CHI97IA195. "The aircraft declared an emergency when the cockpit
filled with smoke. The smoke immediately stopped when the generators
were taken off line, according to the captain. He said the cockpit
smoke had cleared completely within about 4 minutes".
According to the NTSB's Valujet Fire and Explosion Group Factual
Report (page 14), 226 feet of generator power feeder "0" gage
aluminum were recovered - but little was recovered
over the forward cargo bay (forward of station 680).
No verbalizations were noted in the Report's cockpit voice recording
to indicate the crew had any awareness of the importance
to shut off the generator feeds or to not reset tripped
circuit breakers. The same was noted in Flight 111s cockpit tapes.
Responses from pilots and mechanics alike to our web site
(http://members.aol.com/papcecst/) show that none were aware of the
FAA's
encounters and Tech Center's findings regarding troublesome wire
insulation constructions.
The importance of the sharing the knowledge and dangers of wire
insulations that burn with heavy sooted smoke that can't be stopped
and evidenced in those FAA Tech Center Reports became our question to
the NTSB chairman, Jim Hall. In a January letter this year, Mr. Hall
had assured us that the Board was "well aware" of the Tech Center
Reports however none of that is evident in this Valujet Final Report.
Instead, a single focus was made upon oxygen
canisters initiating that fire
and a helpless plunge to impact followed. All other evidence contrary
to that was discarded in a manner not permitted in any other
investigative process.
All the aircraft systems are dependent on wire systems gathered in
bundles that last saw the light of day when the aircraft was built. A
fire in any one system can create havoc and rapid catastrophic
failures across any systems in that, or adjacent bundles. With
greater than a 2,000-degree wire insulation fire described in the FAA
(Cahill) Reports all wire bundles become mere fuel for the ensuing
fire and continuous smoke.
FRANK TALK FROM THE TOP -
SUMMARY
Some 19 months from the White House commission on aviation safety,
FAA administrator Garvey has now said; "The practices and criteria in
place today do not adequately address the issues
posed by aging systems. The problem is compounded by a monumental
data problem. Reporting of wire failures remain problematic. Trend
analysis is not possible with existing databases. (regarding
'Kapton'), Garvey continued) "We will look at it again, setting all
prejudice aside." Does this sound more like 'SMOKE and
MIRRORS'?
Prejudice indeed; in the NTSB Valujet Report, alone,
considerable evidence that countered the
FAA/NTSB's oxygen canister and helpless plunge conclusion was either
omitted or
altered to support the canister theory and
conclusion in the Final Report. A partial list of that evidence
includes;
a. The eyewitness accounts to level controlled flight above the Everglades were edited out; accounts of the final vertical plunge were left in. A false account was added. Item 3.
b. The Report adopted a draft and preliminary FAA Report as findings into it's Final Report. Item 6.
c. The Report's claims to heightened oxygen levels promoting an accelerated fire were not supported in (the NTSB's adoption of) the FAA Fire tests. Item 7.
d. The Report ignored the FAA Fire Test measurements to lower O2 canister exterior temperatures but then adopted the manufactures conservative higher data as fact. Item 8
e. Individual O2 canister tests for 'jostling' were among those not completed. Item 9 The 'ruptured tire scenario' conflicts with industry practice and handling for "removed units".
f. It was empty. Item 11.
g. The 'ruptured tire scenario' omits the effects and release of fire inert nitrogen into the sealed cargo compartment. Item 12.
h. A Valujet mechanic's admissions to substantial and dangerous pre-crash electrical troubles were left out. Item 15.
In addition, the follow errors were noted;
i. The 'ruptured tire scenario' claim to being sensed in the FDR and the assumed fire time line was impossible. Item 10.
j. The claimed shipping document was for the wrong day and the wrong serial numbered parts. Items 13 & 14.
There is much more and that's
why this NTSB Final Report and investigation must be reopened.
Valujet was no less than the 10th
such DC-9 event. The actual number remains elusive. This should not
be so. The Report is an affront to the public's right to a proper and
fair analysis of every air accident and a report absent of opinions
and unsupported data. This critique now becomes the basis for a
criminal
complaint and for
referral to the
Investigator Generals
and various other agencies because of sufficient evidence that such
material facts were concealed or altered to fit a single (oxygen canister/helpless plunge)
scenario.
The following applies: Title 18 U.S.C. s2 26, aiding and cover up of an offense. Title 18 U.S.C. s371, insure that aircraft are properly maintained and safe to fly. Title 18 U.S.C. s1101 25, conceal by trick material facts and false representation. Title 18 U.S.C. s1341/43, use of interstate wires to defraud. Title 18 U.S.C. s1505, obstruction of proceedings, false testimony, creating bogus records. Title 18 U.S.C. s1512, engaging in misleading conduct.
The NTSB's INTEGRITY, CREDITABILITY and ability to
investigate any airplane crash, PAST or PRESENT is questionable, in
light of this MISLEADING Final Report concerning VALUJET 592! It
cannot be excused under ANY circumstance. People
died ! More people will
die until Congress acts to get the FAA, NTSB, DOT
and the Airline Industry to make the necessary changes for the sake
of Air Safety for passengers and crew members. A
copy of this report will be sent to every member of Congress. If you
are a concerned American citizen, you will also make your voice heard
by your congressional members. People power is what they listen to.
SPEAK!
Lastly, this is being supplied to the FAA and Mr. Hall, Mr.Francis,
Mr.Hammerschmidt, Mr. Goglia and Mr. Black, all of the NTSB, and who
signed off on this NTSB Valujet Final Report (NTSB/AAR-97/06). In
fairness, their supported counterclaims and comments will be posted
as well as this complaint in various releases, throughout the
Internet and media.
John King, licensed FAA inspector, (lic. A
& P# 152888)
Patrick A. Price
10/11/98
