[conspire] [OT] I send mail

[Rick Moen]

[Mark Weisler, you'll notice some minor fudging where I reattribute,
for simplification, some stuff you recent called my attention to, to
a long-ago conversation with my Uncle Joe Delong.  He and I did have a
conversation, but not with that high a degree of detail.]


Submitted via CGI form to Web site code7700.com.  See URL in 1st
paragraph to see why this chucklehead annoyed me.  (Why does it matter? 
James 'Eddie Haskel' Albright's derisive blame-the-dead-guys hit piece
is a top hit on Web searches for Pan Am Flight 799, along with the
no-longer-sucky Wikipedia article.)



Eddie, you ought to revise what you say on
https://code7700.com/case_study_pan_am_799.htm , because you made some
serious errors that malign the long-dead crew.  They're 52 years past
caring, but you're telling a false story contradicted by both the NTSB 
report and expert opinion -- a bad thing in itself and also hurtful to
people who knew those men.

Let me recount, close as I can remember, an explanation of the crash I
heard in the '80s from senior Pan Am Captain Joseph Delong:

  "This was at the height of the Vietnam War, and we called the frenzied
  morning rush to make assigned slots for crossing the Pacific the Conga
  Line.  Remember, this was before the 747, so everyone had to have a
  stop in either Hawaii or Alaska, so morning takeoff from either was
  congested.  The traffic congestion and repeated stop-and-start in the
  predawn fog at an unfamiliar field was a small part of the problem.
  A bigger problem was a Pan Am and Boeing screw-up in failing to fix the
  takeoff attitude warning system.

  The attitude warning system consists of a lift transducer on each wing
  to measure air flow near the leading edge, two flap potentiometers, a
  pair of (pre-computer) summing units, a control column shaker motor and
  test switches on the overhead panel.  During takeoff, it's a safety
  backstop for the pilots to tell them instantly give audible warning (a
  horn) to say that control surfaces are mis-set for takeoff, including if
  flaps aren't set to 14 degrees as per the flight operations manual, or
  if speed brakes or stabilizer were mispositioned.  The system got armed
  (activated) when the pilot-in-charge advanced thrust levers to 42
  degrees during takeoff powerup.

  Boeing had discovered a problem:  If it was really cold out, thus really 
  dense air with high lift, crew wouldn't need to apply 42 degrees of
  thrust lever advancement to achieve takeoff.  So, Boeing warned airlines
  owning all B707-321C airframes, via a somewhat vague Service Bulletin,
  recommending changing the trigger point from 42 degree to 25, but the
  wording was vague (talking about 'cold-weather operations' without
  defining that, and making the change 'recommended' rather than
  'required'.  Then, two separate groups of idiots at Pan Am's engineering
  groups decided, inexplicably, that the Service Bulletin was inapplicable
  to Pan Am airframes, and signed off on ignoring it, even though Service
  Engineering had carte blanche to make sub-$500 fixes and just expense
  them.  This stupid decision, along with an incomplete preflight
  checklist, cost three lives and a $10M airframe.

  The checklist was the final piece of that disaster.  The pilots did
  everything right, but got mislead.  Running through the TAXI checklist
  phase, the first officer lowered flaps as shown there, but then the
  captain raised them again because the 'taxiing' portion of the
  B-700-series operating manual requires that during cold weather flaps
  should be retracted to prevent ice from jamming them.  He and the first
  officer discussed this, and said they needed to make a point to revisit
  flaps, a tip-off that the PRE-FLIGHT checklist was incomplete:  TAXI was
  the only takeoff checklist phase that mentioned flaps at all.

  So, all the pieces were now in place for the disaster:  After more
  distracting conversations with ATC about extending their void time
  again, First officer Markstein applied takeoff thrust, silently _not_
  triggering the takeoff attitude warning system because of the cold,
  dense air, the airframe entered a slow climb, gradually lost stability,
  and impacted terrain 59.2 seconds after applying thrust.  The record
  shows that the pilots were working through the emergency checklists
  diligently, but just didn't have enough time to find the problem, and
  lack of anything from the attitude warning system horn steered their
  attention away from flaps until too late."


It's been well over 30 years since Captain Delong told me that, so
consider the indictment of Pan Am and Boeing in Captain Brian
Power-Waters' classic book _Safety Last: The Dangers of Commercial
Aviation: An Indictment by an Airline Pilot_ (1972):


  "Captain Arthur Moen, forty-seven, First Officer Johannes D. Markstein,
  thirty-eight, and Flight Engineer James R. Skellenger, thirty-one, have
  all made their final flight for Pan American Airways.  On December 26,
  1968, their 707 crashed on takeoff at Anchorage, Alaska.  A $10 million
  machine and a crew that no money can replace lay in a fiery heap at the
  end of runway 23.

  A large part of the blame can be attributed to Pan Am, and more directly
  to one of its engineers.  Investigators discovered that the all-cargo
  flight attempted to take off with the flaps in the 'up' position.  All
  large aircraft are required to carry a given amount of flaps for
  takeoff.  This aerodynamic lift-and-drag device enables a plane to take
  off in a much shorter distance.

  The cockpit voice recorder was recovered and played.  There was no
  audible sound of a flap takeoff warning horn.  This horn is a backup for
  the check list.  If it blows when the throttles are advanced, it
  immediately signifies to the pilot that one of three items is not in its
  proper place: flaps, spoilers (sections on top of the wing that extend
  to reduce speed on landing), or tail trim setting.  Why didn't the horn
  blow?

  During the early part of the investigation, it was determined that
  Boeing Company issued a service bulletin, #2384, on January 31, 1967,
  twelve months before the fatal accident.  It stated that in cold-weather
  operation the horn would not blow unless the actuating stops of the
  throttles were reduced from 42 to 25 degrees of thrust-lever
  advancement.  A similar service bulletin was also transmitted to cover
  the 727 series aircraft.  (During cold weather, the air is more dense,
  and higher-power setting will be obtained with less movement of the
  throttle.  In this case, the throttles weren't advanced far enough to
  actuate the horn, but still the required thrust was obtained.)

  The service bulletin issued by Boeing carried the word 'recommended'
  rather than stronger advice.  Boeing obviously felt that the various
  airlines would comply with such an important request.  The FAA should
  have demanded it.

  One of Pan Am's engineers received the service bulletin from Boeing and
  questioned other interested people in his company, i.e., maintenance and
  flight operations.  Some of the factors considered during the review
  were the frequency of exposure their craft would be subjected to, and
  the relationship of safety to this bulletin.  If a determination was
  made to adhere to the directive and the total cost was under $500 (as it
  was in this instance), a modification request would be prepared.

  However, an engineer decided that the bulletin was not applicable to Pan
  American, and no further action was taken.

  In response to the safety board's inquiring concerning the reasons for
  nonimplementation of the service bulletin, Pan Am cited the following
  reasons:

    1.  There was no aircraft crash on record relating to the lack of this
    modification.

    2.  The FAA did not demand that the bulletin be complied with.

    3.  Other air carriers also elected not to comply with the bulletin.

  Pan Am should have been ashamed of such lame excuses.

  A playback of the tape showed that Captain Moen was indeed following
  company procedures when he started his taxi to the runway.  The F/O was
  running the check list and placed the flaps in takeoff notch, but
  Captain Moen returned them to the full 'up' position.  The company
  Operations manual states:  'The wing flaps should be left in the full up
  position until lined up for takeoff.  This would reduce the chance of
  snow and ice being blown onto the flap mechanism.'

  Positioning the flaps for takeoff appears only on the taxi position of
  the check list.  There is no mention on the pre-takeoff section of the
  list to remind the pilot to lower the flaps before it is too late.  FARs
  plainly state that a pilot must not rely on his memory alone to perform
  various functions.  A check list must be used.  Here is a conflict
  between FARs and an adequate check list.

  The check list used by Pan Am and many other carriers leaves a lot to be
  desired.  There are in use today three distinct types of lists:  (1) a
  plastic card; (2) a scroll; and (3) the most expensive and best, the
  mechanical list.  This check off list embodies a lighted background and
  a series of tabs that can slide over the telltale light when the
  required item is completed.  If, as in the case of Pan Am, an item is to
  be skipped, such as the flaps, the tab will remain in its stowed
  position signifying at a glance the parts of the list that have not been
  completed.

  On May 28, 1969, five months after the accident, the FAA finally got
  around to issuing an airworthiness directive that made it mandatory to
  comply with the horn setting on all 707 and 727 series aircraft."



I never met Capt. Power-Waters, but have had the pleasure of discussions
with NASA-Ames's Prof. Asaf Degani, expert on checklists, human factors,
and crew resource management (CRM), author of, among other things, the
pivotal monograph Cockpit Checklists: Concepts, Design, and Use
(https://ti.arc.nasa.gov/m/profile/adegani/Cockpit%20Checklists.pdf).
Here's his section discussing Flight 799:

  "The Safety Board had previously recognized the importance of checklist
  use and its critical role in the safety of flight operations in a 1969
  recommendation following a Pan American World Airways B-707 crash after
  a no-flap takeoff. This recommendation called for “Air carrier cockpit
  checklists to be reviewed in an effort to ensure that each list provides
  a means of reminding the crew, immediately prior to takeoff, that all
  items critical for safe flight have been accomplished” (NTSB, 1969).

  It took 18 years and a tragic accident before the Safety Board
  recognized the problems with the human factors aspects of checklist
  design, display, and procedure. Following the Northwest accident, the
  NTSB recommended that the Federal Aviation Administration (FAA) convene
  a human-performance research group to determine “...if there is any type
  or method of presenting a checklist which produces better performance on
  part of user personnel,” and for the FAA to recommend checklist
  typography criteria for commercial operators (NTSB recommendations
  A-88-068 and A-88-072)."

Prof. Degani called the Flight 799 disaster pivotal in _inventing_
the concept of CRM and the study of human factors.  They didn't exist
before.


So, two world experts _plus_ the NTSB and FAA judged one of the primary
causes to be a defectively incomplete checklist -- but you on your page
breezily call it 'case of a crew's poor checklist discipline'.

I have a bit of a problem with that.  First, it's dead wrong.  Also,
it's a bit personal.  Pan Am Captain Delong, who first explained the
root causes to me, was my Uncle Joe, and Pan Am Captain Arthur Moen
was...  Dad.  Pan Am and Boeing's negligent killing of him and his crew
was their slightly belated Christmas gift to me and to (what remained of)
my family, when I was 10 years old.

Your erroneous article blame the crew for not being in the 'fly the
airplane loop', blame Pan Am for a poor CRM culture, and cite a 'climate
where challenging the captain was received poorly'.  Actually, first, 
the entire field of CRM and the concept of the PIOSEE and tDODAR
decision loops hadn't been invented in 1968.  They were invented largely
_because_ of lessons learned from this and other disasters over the
succeeding decade-plus. 

And, actually, Dad was top of the list -- and I mean that literally --
of Pan Am captains whom co-pilots wanted to fly with, specifically
because he was consultative by nature, supported his crew, and wanted
his first officers to work closely with him.  Pan Am at one point
surveyed all captains to rank first officers as to whom they'd most and
least like to fly with, and vice-versa -- but then in subsequent
scheduling paired up the least-liked captains with the most-liked first
officers, and so on, figuring this would even out personnel problems.  A
dirty trick to pull on their employees, but they did that sort of thing.


So, I really think you ought to revise or 'pull' your rather dreadfully
misconceived article.  Because it's embarrassingly wrong and maligns the
dead.  And that's the job of the airlines, isn't it?  Burying their
mistakes by blaming dead pilots?  That's the way I always heard it.

I don't expect you to fix your piece, because it's the path of least
resistance to either ignore this feedback or dismiss it with a
non-apology apology along the lines of 'I'm sorry if I gave personal
offence' (etc.).  

If inclined to send me a response and _not_ fix your piece, please 
don't bother.  Seriously. 

Sincerely,
Rick Moen
rick at linuxmafia.com