MESSAGE
| DATE | 2016-10-31 |
| FROM | Rick Moen
|
| SUBJECT | Re: [Hangout-NYLXS] what happened to your Dad at Boeing ? ( if not
|
Quoting Mancini, Sabin (DFS) (Sabin.Mancini-at-dfs.ny.gov):
> Rick, Can you go into specifics of what happened to your Dad at
> Boeing, if I may ask ? Just interested in what happened. If not, I
> understand.
No worries.
Norwegian-born Arthur Moen of San Mateo, California was captain of a
long-haul cargo flight, Pan Am flight N799PA, from San Francisco to
Anchorage to Tokyo to Danang to Cam Ranh Bay. The crew arrived in
Alaska at 03:30 on Dec. 25, 1968, and went to their hotel, then were
woken up at 02:15 to go back to Anchorage International Airport. There,
Pan Am Operations Office told them they'd be flying their outbound
B707-321C jet, Clipper Racer (N799PA), from Elmendorf Air Force Base
where it'd been diverted for weather reasons. So, they were bused over
to Elmendorf to prep. for early-morning takeoff on Dec. 26th. In
consequence of diversions, the following early morning had a tremendous
backup of planes lined up for takeoff, hence nobody was taking any spare
seconds getting off. The plane began taxiing from the ramp at 06:02.
I have a copy of the NTSB crash report here, courtesy of a friend who
pointed out it's the 21st Century and such things are on the Internet --
who heard me say I'd never seen the report, because I figured it was too
painful a subject for me to raise with my (now-late) mother.
http://linuxmafia.com/~rick/pan-am-crash-report.html
The Board determines that the probable cause of this accident was
an attempted takeoff with the flaps in a retracted position. This
resulted from a combination of factors: (a) inadequate cockpit
check-list and procedures; (b) a warning system inadequacy associated
with cold weather operations; (c) ineffective control practices
regarding manufacturer's Service Bulletins; and (d) stresses imposed
upon the crew by their attempts to meet an air traffic control
deadline.
(Sorry about the quality of the converted PDF. I probably should have
chased down a better copy, but I was a little rattled by reading it at
the time.)
Er, there's a better copy here:
http://www.ntsb.gov/investigations/AccidentReports/Reports/AAR6908.pdf
(Obviously, all online copies are scanned and sometimes OCRed from
paper. The above one is a bitmap of someone's paper copy, a true blast
from the past.)
Unpacking and further explaining that summary paragraph a bit:
Flaps need to be extended on a B707 to a certain number of degrees, with
the number of degrees in cold weather (such as Alaska on Dec. 26th)
differing from during normal operation. But there's also a slightly
conflicting requirement, that the flaps be kept retracted ("up"
position) as long as possible before takeoff, when doing cold weather
operations, because otherwise the flap screws can and do ice up,
creating huge and potentially fatal problems.
Captain Moen followed takeoff checklist procedure exactly. So did
Johannes D. Markestein. Unfortunately, Moen and Markestein worked at
cross-purposes. During taxi, Moen made sure the flaps were up so they
wouldn't freeze, advising Markestein, who acknowledged that. Before
that exchange, and right at the very beginning of the checklist's taxi
phase, Markestein had set flaps extended to 14 degrees for takeoff, as
they needed to be during takeoff phase. Critically, the checklist did
_not_ include an item to ensure that flaps are set at lineup for takeoff
on the runway. Instead, there was another oral conversation between the
crew-members, trying to compensate for the broken checklist. Moen:
[something like a reminder that he'd raised the flaps]. Markestein:
'Oh, OK, let's not forget them.'
The _only_ reference to flaps on the checklist was in the taxi portion,
which said to retract them.
Crucial factor, the B707 had a Takeoff Warning System to advise the crew
of configuration details (flaps, speed brakes, stabiliser) that aren't
yet right for takeoff. (This is one reason for the defective checklist.
Apparently, crews relied on the TWS to catch no-flaps conditions.) This
sounds a horn if there's a problem, and was tied into the throttle
control. If the throttle gets pushed to 42 degrees (normal takeoff
thrust), the resulting high-enough amplitude of Exhaust Pressure Ratio
(EPR) triggers TWS, which initiates check of controls, and sounds a horn
if there's a problem.
NTSB investigators were initially perplexed that there was no TWS horn
on the wreck's Cockpit Voice Recorder tape. The reason was clarified
during further digging: Cold-weather operations don't require anywhere
near as much takeoff thrust _because_ cold air is much thicker, hence
provides a lot more lift. So, the pilots weren't going to apply 50
degrees advancement on the thrust lever. The ambient temperature on
this day at 5:55am when this (short, unhappy) party started was 1 degree
F with fog.
But surely this was a known problem? Yes, it was. Boeing had issued
Service Bulletin 2384 on 1967-01-31 warning that in 'cold weather
conditions' (term undefined in the bulletin), TWS would fail to trigger
because, as mentioned, EPR wouldn't be high enough. Accordingly, Boeing
recommended a field service procedure to change the thrust lever setting
from 42 degrees to 25 degrees. I'm guessing this was a new switch
setting, 42 or 25. (The 25 degree setting makes the system functional
down to -42 degrees F.) They'd already retrofitted this change into
production half a year before, but took their sweet time advising
customers who'd already bought the 508 prior units. Clipper Racer was
1965 production.
Airlines such as Pan Am were legally required to comply with Air
Transport Association Specification 100, which says that airlines should
comply with all Service Bulletins that are designated as 'recommended'
(as this one was) _unless_ one of three exception criteria apply,
including one that amounts to 'airline nonetheless doesn't think it's urgent'.
Manufacturers have the option of designating a Service Bulletin as
mandatory, in which case FAA orders the airlines to just do them -- but
Boeing _didn't_ bother to do this.
Records show that Service Bulletin 2384 reached within Pan Am 'one of
the supervisors of an engineering section within the operations
engineering group'. The name of this genius is not recorded for
posterity (and I devoutly wish I'd known the gentleman's name). Pan Am
company policy was that Service Bulletins would be routinely treated as
'just do it' if it cost less than $500, and then expensed as maintenance
-- unless a service manager decided it was not necessary. If it cost
over $500, it was carried out and capitalised.
This time, the unnamed luminary in question decided, 'after coordination
with flight operations, that the bulletin was not applicable to Pan
American aircraft and no further action was required. The reason for
this decision was not fully documented.'
In its defence, when Pan Am was asked why it didn't implement Service
Bulletin 2384 until a five-million-dollar plane, three lives, and a
small transmitter shack had been destroyed, they said:
1. Gosh, we didn't know what 'cold weather conditions' meant.
2. Besides, if this were serious, wny didn't FAA make it mandatory?
3. And other carriers made this hapless screw-up, too, so don't blame us.
Five months after this crash, partly because of this display of Global
Village Idiocy, and partly because of waves caused in the industry by my
mother starting to go after Boeing, FAA issued (May 26, 1969) an
Airworthiness Directive making compliance with Service Bulletins
mandatory. (FAA had also telephoned airlines, four days after the crash,
advising of the cold-weather problem on 707 and 727 airframes.)
I should mention, in this connection, that airlines are held immune from
civil negligence litigation from employee widows/widowers by workers'
compensation laws that limit recourse to a small amount of insurance
money and prohibit suing for liability.
While taxiing and preparing for takeoff for 20 minutes, the crew were
also stuck in a great deal of interaction with multiple ATC (air traffic
control) facilities, doing calculations (slide rule!), dealing with
slippery asphault at an unfamiliar airport on a foggy night, and
handling some unusual confusion reschedulings of takeoff slots, plus a
runway change (to one with greater effective runway length) -- all while
under pressure to hurry up because of a full takeoff schedule. (Air
crews called this the 'conga line'. This area was super-busy because of
the Vietnam War.)
Taxiing ended at 06:10 with the usual hold-for-your-turn, and clearance
came through at 06:14:30.
The crew applied thrust for takeoff at 06:15. The temperature was now
6 degrees F. Subsequent post-crash testing of a B707 TWS showed that it
would not have triggered below 34 degrees F. Visibility ceiling was
200 feet. It was of course dark.
I am not a pilot (to avoid freaking out Mom, and because Moen 2.0 tries
to make _only_ new and different mistakes), but am told that pilots call
out several important speeds (https://en.wikipedia.org/wiki/V_speeds)
during takeoff:
1. When you reach 120 knots (138 mph). They did this.
2. When you reach the V-sub-1 speed. This is 'critical-engine
failure speed', the speed beyond which you cannot safely abort
the flight, because you would then run out of runway, etc. and
do a ground crash. The crew had precalculated this as 148 knots
(170 mph), and did call it out.
3. When you reach the V-sub-R speed, which is the correct 'rotation'
speed, the speed at which pilots apply aileron control to pitch-up
for takeoff. The crew had precalculated this as 154 knots (177 mph),
and did call it out.
4. When you reach V-sub-2, the takeoff safety speed, which is the speed
at which the aircraft may safely be climbed with one engine inoperative.
The crew had precalculated this as 167 knots (192 mph), but there's no
callout on the CVR for it, because they never got there.
Stickshaker was heard on the CVR shortly after VR. This indicates risk
of stall. Estimates of the plane's peak altitude differ. Some say 10
to 20 feet elevation above terrain; some say 150 to 200 feet. It
exhibited progressive loss of attitude control, crashing right-banked
and nose-down, half a mile from the end of the runway, 59.2 seconds
after applying thrust for takeoff.
Impact speed is not indicated, but presumably about 180 mph. As NTSB
pointed out, this crash was non-survivable. And then there was a fire.
NTSB, in a special report, made a particular point of ruling out 'pilot
error', pointing out that 'it is obvious that the possibility of such
"error" was considered by the manufacturer and others to be within the
normal range of human performance. Otherwise, there would have been no
justification to install the takeoff (flap} warning system in the first
place.
I've never enjoyed Christmas since then. Or December.
http://linuxmafia.com/faq/Essays/christmas.html
Two days after the crash, on Saturday, December 28, 1968, young newly
widowed Faye Moen answered the door, and it was two private detectives.
I'm not entirely sure they identified their employer, so I won't say it
was Boeing Corporation. They worked rather hard at convincing Mrs. Moen
that it would be an extremely bad idea to sue that corporation for civil
negligence. After all, it was pilot error, they said. Moreover, they
darkly suggested that there were probably (unspecified) secrets in her
late husband's, or in her own, pasts, and surely she wouldn't want those
to emerge into public view? If that happen, who would take care of her
10-year-old son and 9-year-old daughter?
Mrs. Moen, gobsmacked but in rising fury, escorted them to the door and
politely kicked them the hell out. (But I doubt there was any swearing,
except perhaps from them: She was a Midwesterner.)
I believe Boeing had identified Widow Moen as their keystone problem:
If they could cow her, then the other two would have been easy prey.
Six years later, after a bunch of other dirty tricks against (what
remained of) my family (like: IRS audits for six years, never before and
never again) had failed to intimidate, and Boeing's stalling tactics had
been exhausted, the civil negligence trial convened for its first day of
testimony in San Francisco's U.S. District Court for the Northern
District of California. As an avid observer of legal follies by this
point, 16-year-old me had a good seat. The judge was admitting
testimony -- a great deal more damning bits of evidence than made it
into the NTSB report (but now sadly under judicial seal), and we reached
the CVR and instrument recorder.
Boeing Chief Litigator: 'Your Honor, it appears that we have misplaced
the tapes.'
Judge: 'You're kidding.'
For context, we-all were just around then making jokes about Dick
Nixon's personal secretary Rose Mary Woods and the 18 1/2 minute tape
gap.
Shaking his head, the judge ordered a recess.
One day later, the Fortune 50 corporation settled the lawsuit on our
terms. As I was walking past Mr. Boeing Chief Litigator Guy, I said:
'Sir, a bit of advice, if you will. _Never_ threaten a Viking widow.
It'll just make her furious and want to hurt you.'
I have never been able to hear the audio of the last minutes of my
father's life, but perhaps that's just as well. Maybe they un-misplaced
the tapes some time in 1974. Could be!
Some other time, I'll tell the story of how I recently got to go on a
private, deluxe tour of Boeing's two huge production facilities and wore
a t-shirt with the inscription 'Hello, my name is Inigo Montoya. You
killed my father. Prepare to die.'
Or you can read it here:
http://linuxmafia.com/pipermail/conspire/2016-August/008514.html
I have a beautiful picture of the long-before-the-day Clipper Racer,
N799PA, on my refrigerator door. Gorgeous craft. Pity what, and all
that.
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