Aircraft Accidents and Lessons Unlearned LIII: Northwest Airlines Flight 255

The resting place of Northwest Airlines flight 255

On August 16, 1987, at about 19:45 (7:45 PM) Eastern Standard Time, Northwest Airlines flight 255 (NWA255) crashed shortly after taking off from Runway 03 Center at Detroit Metropolitan Wayne County Airport in Romulus, Michigan (MI). The Douglas DC-9-82 aircraft, registration number N312RC, failed to climb out before striking light poles, a building’s roof, then the ground. The aircraft broke up as it slid, never veering from its takeoff heading.

The same pilots were flying this third leg of four bound for Phoenix, Arizona, that originated in Minneapolis, Minnesota. The National Transportation Safety Board (NTSB) assigned NWA255 accident number DCA87MA046; Accident report AAR-88/05, published on May 10, 1988, stated, “… that the probable cause of the accident was the flight crew’s failure to use the taxi checklist to ensure that the flaps and slats were extended for takeoff.”

The probable cause was correct. Examination of the cockpit voice recorder (CVR) showed that during taxi out on departure, the flight crew did not run the preflight checklist and, based on the flight control positions found after the accident, did not extend flaps and slats for takeoff. Unlike the stabilizer trim being set without verbal confirmation (the sound of the stabilizer trim ‘in-motion’ horn recorded on the CVR), there was no aural indication that flight controls were extended. From here the report should have examined why the pilots did not run the preflight checklist, to get to the Root Cause of the accident, whether it was a failure on the airline’s procedures; a lack of productive check rides or even something human factors related. However, accident investigators failed to pursue Root Cause.

The report’s reference to the takeoff configuration warning system (TCWS) and its apparent electrical failure diverted attention away from the sole probable cause: pilot failure to use the checklist. As AAR-88/05 stated in the Probable Cause, “Contributing to the accident was the absence of electrical power to the airplane takeoff warning system which thus did not warn the flight crew that the airplane was not configured properly for takeoff. The reason for the absence of electrical power could not be determined.” This was a coincidence that the pilots’ break with procedure aligned with a system that did not function correctly, but should the TCWS have been a contributing factor or a Finding?

Using the accident number, DCA87MA046, the NTSB docket page was queried for Field Notes and Team Lead Factual Reports, especially the Systems Lead’s TCWS notes. The Docket Search Result, however, was “Zero Dockets” as was the docket search result for Delta Airlines flight 1411’s accident report notes, which will be discussed later.

To be clear, the TCWS is a redundant system; its purpose is to alert the pilots of the misconfiguration. TCWS is not designed to remind pilots nor is it a hazard warning in the course of normal flight, e.g., terrain or pending midair collision warnings. Although, the TCWS warns when procedures are not followed, it should never be relied upon to sound. TCWS is a last resort, designed to never be used. It was not an accident cause nor was it a contributing factor. The NWA255 pilots’ failure to run the preflight checklist was the only Probable Cause. The checklist failure, however, was not a Root Cause.

This distinction is important because responsibility – in some cases, as in NWA255, sole responsibility – needs to be defined. If we are to learn the true lessons from aircraft accidents, we must ignore unrelated distractions and narrow the initiates down to root causes, otherwise the lessons are clouded. In this case, the cause was procedural; the NTSB focused attention away from the pilots and called for technology to fix the problem, clouding the problem even further. This diminished pilot skills, their responsibility given to technology. Pilots became more obsolete.

What was the TCWS? The TCWS in the NWA255 DC-9-32 was a mechanical system that employed a series of switches and sensors that reacted to the position of, e.g., the engines’ throttle cables, landing gear sensors, cable or hydraulically driven flight control drive units. TCWS could also work during the landing cycle, assuring flight controls and landing gear were in position for approach and landing. Compared to today’s digital TCWS, the warning system was very rudimentary, but effective. If the flaps, slats, landing gear and/or spoilers were out of takeoff configuration, an alarm horn would sound. It was unlikely that the TCWS was a deferrable item; if non-functional, the plane was not airworthy until repaired.

However, if the TCWS were recognized as a cause, NTSB investigators made a significant omission by not interviewing the Minneapolis maintenance crew and another error by ignoring the maintenance history. It was a critical mistake that Maintenance information and research was absent. Had the throttle cables recently been replaced; the flaps rigged; the landing gear time-changed? Had the mechanic in Minneapolis moved the throttles forward to see if the horn would sound? Was there a preflight inspection conducted by Maintenance and, if not, why not? This could have led to proactive recommendations.

Which is why the NTSB’s fixation with an alleged TCWS electrical system power loss was odd. The docket was empty of any enlightening data related to what the NTSB Systems engineer proved or if he/she was looking in the right place. During the aircraft breakup, sensors were jolted out of place; cables became excessively stretched or broken. It also, unless circuit breakers were physically open, raised the question: How did the Systems engineer determine that power was not available to the TCWS? More importantly, why was the supposed electrical power loss considered a contributing factor?

This is why going off on tangents was wrong. It was dangerous to divert resources and attention away from the investigation path. Additionally, the Probable Cause was for serious information. Investigations that branch off into unrelated departures, leaves the correct causes to be diminished, to get lost in the minutiae of other theories. Speculation should be raised in the investigation’s Analysis phase; if it cannot be proven it should not make the accident report and should be edited out with other theories. If the Systems investigator gave credence to phantom electrical problems, why not question a TCWS sensor design; a switch location; a throttle rigging procedure? All of these components could have just as easily affected the TCWS warning horn. Where would speculation end?

The investigator spent four pages of the report talking about an electrical problem that could neither be found nor proven even existed. In those four pages the investigator did not move the investigation forward, nothing productive was learned. Was the investigator-in-charge unable to bring the conversation back to facts?

It was unclear from the accident report, whether TCWS function was confirmed by the flight crew since the CVR transcript began after the pilots conducted their pre-flight. Any aural warning checks performed by the flight crew during their pre-flight were omitted from the CVR transcript. Even if the CVR transcript recorded the pilots’ pre-flight check, the TCWS could have malfunctioned during pushback or taxi-out. During a review of the transcript, there were five unidentified identical noises titled: “((sound of click))” that occurred between 20:43:11 and 20:44:39 as the aircraft was powering up for takeoff and running down Runway 3-Center. Was this the TCWS aural warning trying to function? The investigator never identified this clicking sound.

It was unfortunate that time was wasted on tangents. Proactive measures could have been worked out with the Federal Aviation Administration (FAA) to identify the Root Causes of the pilots’ failure to follow procedures. On August 31, 1988, 381 days after the NWA255 accident (113 days after AAR-88/05 was adopted), Delta Airlines flight 1141 (DAL1411) crashed during takeoff at Dallas-Fort Worth International Airport. The DAL1411 accident report, AAR-89/04, stated as the Probable Cause, “(1) the Captain and First Officer’s inadequate cockpit discipline which resulted in the flight crew’s attempt to take off without the wing flaps and slats properly configured.”

Following AAR-88/05’s adoption, the FAA issued Air Carrier Operations Bulletin #8-88-4 in June 1988; the Delta Certificate Management Office received Bulletin 8-88-4 on August 30, 1988, and Delta received the bulletin on September 5, 1988, five days after the DAL1411 accident. Bulletin 8-88-4 directed an airline’s FAA Principal Operations Inspector to review, “… overall takeoff warning system performanceand ensure that the checklists appropriately support required crew actions …” Checklist non-compliance was the fundamental cause of NWA255 and, unfortunately, DAL1411. With NWA255 having occurred over a year prior, its investigators might have prevented DAL1411, whose pilots did not run the preflight checklist, just like NWA255’s pilots.

AAR-88/05’s recommendations were toothless, as if the NTSB called them in. Expedite the issuance of guidance materials? What does that mean to the industry? Have Principal Operations Inspectors emphasize the importance ‘disciplined application of standard operating procedures’; ensure training includes cockpit resource management? These were not recommendations; they were the restating of the obvious. If Northwest Airlines messed up their required training, then say so; state it clearly.

Finally, two points about why analysis of 34-year-old accidents is important, especially when digital aircraft monopolize our skies. First, the NTSB has not changed its approach to accident investigation procedures; they still employ decades-old practices, e.g., using engineers with zero industry experience, who do not understand airline culture. That is why all Maintenance issues were missed. Second, the NTSB did not get NWA255 right. What improvements, then, have been implemented into the aviation industry today? If the fixes were wrong in 1988, are we any safer in the 21st century?

Aircraft Accidents and Fabricating

Battle of Monmouth during the War for Independence

Of all the young of the animal kingdom, the most helpless at birth is the human. Whether due to overprotective human emotions through evolution or natural instinct, the human infant is heavily reliant on its parents for everything. Often, the only way a human child can communicate its distress is through crying, loud and long, until it is satisfied. Amazing how adults today, especially politicians, continue to cry, loud and long, about manufactured issues. One could make a killing in the adult pacifier business. Professionals, concerned with aviation safety, are being drawn into a political battle of social justice.

In 2001, after the 9/11 attacks, it took several days before civilian flights were back in the air. However, per the Bureau of Transportation Statistics, it took three years for the industry to recover to pre-9/11 levels. Last year’s strains dwarf the aviation impacts of 9/11 where Aviation’s losses took place over months, not days. Recovery will take a lot longer. Pilot training issues; Federal Aviation Administration (FAA) oversight backlogs; internal audits of operators and repair stations all demand attention. In the meantime, Politicians focus on Aviation, hobbling our industry with fears of new COVID strains, while fabricating new divisive agendas, the latest: Diversity and Inclusion.

Is Diversity really a problem in Aviation? Impossible to prove either way with no existing resources for Facts, data or evidence. For unskilled labor, evidence depends on many factors, e.g., location, cost-of-living, etc. Among skilled labor? Not likely. Forty years ago, I was unskilled labor in Kennedy and LaGuardia, where there was a healthy mix of all races and both genders. Later, as an FAA-certificated airframe and powerplant (A&P) technician, race or gender were irrelevant; the job depended on skill, certification and experience. When in management in Newark, I could not hire diversely for skilled positions because a diverse candidate pool did not exist. That is the reality, whether one chooses to believe it or not. If tangible data exists that the Aviation industry is racially corrupt, it must be presented. Allegations, based solely on feelings, are destructive.

Many high-paying positions in Aviation require skilled individuals. There are entry-level positions, but the more challenging require FAA-certification. Even so, not every FAA-certificated pilot can fly an airliner nor FAA-certificated technician troubleshoot a digital navigation system. Among numerous factors that affect an aviation candidate’s hiring are passing a check ride or furlough recalls. A job candidate is not defined by race or gender; skill has nothing to do with Deoxyribonucleic Acid – DNA.

Recently, the Media, some airlines and aeronautical school leadership, would have us believe that the greatest threats to aviation safety today are racism, gender-bias and inclusion. To the thousands of dedicated men and women I have worked with of all races, who have been improving aviation safety for generations, this news must have been a surprise, to learn that Safety can be improved by a concept such as Diversity. The answers, as suggested, are in people’s hearts, not in Root Causes or Facts.

This is a divisive phenomenon that has been escalating for several months. How many friendships, marriages and families were destroyed for having the ‘wrong’ view on any topic that may be hindered by bothersome Facts of any kind. For example, with the unending ‘threat’ of COVID, why not close the border, or at least control access since many confirmed cases are crossing in? Is that racist or common sense? Some people, who do not know me, would call my way of thinking ‘racist’.

There are two problems with this emotional name-calling. First, COVID and ‘racism’ are fundamentally dissimilar; they have nothing to do with each other. Second, calling someone ‘racist’ dodges the question; it is a social justice tactic to distract from the discussion and, thus, a solution. But maybe distraction is the idea. Responses like ‘Nazi’, ‘Hitler’, ‘Racist’ are distractions. They serve no logical purpose, solve no problem. Challenge climate change? You’re a ‘climate denier’. Question COVID vaccine safety? You’re an ‘anti-vaxxer’. Question Diversity as a job qualifier in a safety-sensitive position? You’re a ‘racist’, ‘homophobe’ or ‘misogynist’.

How do we know racism and gender-bias dangers exist? For one, government is telling us so. The FAA will spend millions to crush alleged gender-bias into dust; a typical government response to a crisis that does not exist, a dilemma in search of a Fact. On June 25th, the United Kingdom’s The Daily Mail reported, “Woke FAA Advisory committee recommends using gender-neutral terms like ‘aviator’ and ‘flight deck’ to avoid offending ‘femme’ workers;” The Washington Post (WAPO), Fox News, etc. also reported this story. A WAPO article by Lori Aratani suggested that the term ‘cockpit’ was not gender-neutral, stating, “… male crew members have sometimes ‘wielded the term [cockpit] to undermine femme workers’”. WHAT? Male crew members “wielded a term”? How does One ‘wield a term’? This makes no sense because Ms. Aratani Fabricated a problem. That is what Media does.

If I ask why terms, like ‘cockpit’, are not gender-neutral, the reply will be, “You’re a misogynist.” Ms. Aratani showed how the Media will not even invest the time to get the story right. They do not respect their aviation audience. Is the WAPO correct? Are professional women victims of pilots who “wield the term ‘cockpit’”? Are female Captains really ‘maidens in distress’ on their own flight deck? Or, perhaps instead, the Media is poo-pooing professional women, painting female Captains as helpless and in need of men to protect them from male chauvinist aviators. It also suggests that reporters, like Ms. Aratani, are not assigned stories despite their ignorance of the subject, but because of their ignorance. A reporter’s lack of topic knowledge generates emotional responses, like name-calling, and cannot be taken seriously.

There is little doubt that the Media has become unreliable; politicians are as well. No sane person trusts the Media (or politicians) and they have no one to blame but themselves. They have regressed into diluted sources of opinion; Facts no longer matter. The Media is hijacking the narrative of our industry and it is not productive. Therefore, are their calls for Diversity and Inclusion justice sober demands?

Inside aviation, there are other serious safety issues, such as political ignorance bleeding into our industry. This obliviousness comes from outside the aviation industry, arguing artificial issues that have nothing to do with how the aviation industry functions. Are these outsiders hijacking legitimate and trusted aviation resources? Last month, Embry-Riddle Aeronautical University (ERAU) called for papers: “Attention writers: The Journal of Aviation/Aerospace Education and Research (JAAER) is proud to announce a call for papers related to diversity, equity, and inclusion in the aviation industry. This special issue will aim to publish thought-provoking scholarly and research articles related (but not limited) to race, age, gender, sexual orientation, religion, and other nascent and incipient forms of inequalities in the context of the organization and work within the aviation and aerospace industry.”

Note how ERAU applied the words ‘scholarly’ and ‘research’ with ‘diversity’ and ‘inclusion’; they have nothing to do with each other. ‘Scholarly’ and ‘Research’ were being used to make ‘diversity’ a valid path to aviation safety. This JAAEC paper mirrored the FAA’s Diversity and Inclusion plan (DIP). The FAA stated on its website, “Diversity is integral to achieving FAA’s mission of ensuring safe and efficient travel across our nation and beyond.” How does Diversity and Inclusion ensure Safety and Efficiency? How strangely unrealistic of the FAA. Has the FAA become UN-diversified since Jane Garvey and Marion Blakey ran it? Look at the FAA’s mission statement: “Our continuing mission is to provide the safest, most efficient aerospace system in the world.” One could conclude that, by promoting DIP as a hiring measure, the FAA has already forfeited their own mission statement. Diversity and Inclusion equaling Skill and Experience as hiring qualifiers? Is this for real?

Diversity is subjective; Aviation Safety is objective. In aviation, the path to Safety is specific, e.g., following a maintenance manual’s instructions, pilot training, deicing an aircraft, etc. In aviation, how does One promise Diversity? The answer is, One cannot. If two men, one Asian without an A&P FAA certificate and one Hispanic with an A&P FAA certificate, apply for the same A&P job, the Hispanic man will get the job because he is FAA-certificated. It has nothing to do with Diversity. This is true with many aviation positions: pilots, avionics technicians, air traffic control, management, airports, inspectors, investigators, auditors. The DIP is disingenuous.

ERAU’s JAAER paper request is just as suspect. ERAU began in 1925. Were they not Diverse in the 96 years before 2021? What took so long to be diverse? This insincerity is troubling. One, some ERAU instructors are not required to be FAA-certificated or experienced, e.g., English and Math teachers. ERAU can hire a diverse staff and should have done so before today. Two, ERAU is also a Trade School with experienced FAA-certificated instructors. The JAAER papers will delegitimize the Trade School qualifications, tying skilled and experienced Trade School Instructors with unskilled Academicians. Many university professors entire careers are behind a podium, never working with data; coining confusing phrases, like ‘ecological feminism’ or ‘nowtopia’, strung together with ambiguous blather. Is JAAER’s integrity being exploited to give credibility to Opinions and Hearsay?

United Airlines announced new Diversity goals that at least half the pilots hired will be people of color and women. How odd. United Airlines has been around for almost a century. Were they not Diverse before this? Why not also be diverse in hiring equipment mechanics, flight attendants, planners, hangar technicians, ramp crews, upper management, flight scheduling, meteorologists, avionics, ramp controllers, gate agents, etc.? Aren’t these positions worthy of notice; don’t their lives matter?

To suggest the USA is a racist and gender-biased nation is ridiculous. Reality crushes opinion because Diversity is all around and in the most obvious places. In Politics: Hillary Clinton, Nancy Pelosi, Alveda King, Barack Obama, Michelle Obama, Ben Carson, Tim Scott, Kristi Noem, Nikki Haley, all political bigwigs. Entertainment: Jennifer Aniston, Morgan Freeman, Angela Bassett, Denzel Washington, etc. all entertainment powerhouses. Media: Don Lemon, Laura Ingraham, Rachel Maddow, Barbara Walters, etc. These people represent both genders and different races; all exemplify the USA’s Diversity and Inclusion. In the Tokyo Olympics, Tamyra Mensah-Stock, an American black woman who won Olympic Gold in Wrestling, said, “I love representing the US. I freaking love living there.” Does that sound like someone who is discriminated against?

Why commit to a course of action that already exists? The FAA committed to Diversity in 2014. It is unclear why the FAA would commit to something it was already doing. Equally puzzling was if ERAU and United Airlines were already diverse, why publicly promise to be what they already claimed to be? Why, indeed. Perhaps they never placed Diversity over Safety. Or, perhaps, some are placating to select groups. Diversity may not be about Safety; it may be about pandering.

Per the New York Post, Fleishers, a New York City major beef supplier was forced to close after employees walked off the job. Why? These employees hung unauthorized signs for an admitted Marxist group in the company’s street-side windows; the Chief Executive Officer removed the signs because they were not approved. The entitled employees ‘felt threatened’ and walked off. How easy it was to cripple a business with politics. A company destroyed by a few signs and the selfishness of entitlement.

What does this have to do with aviation? Many know the grey area where political, religious or social ideology holds businesses captive, corrupting a business’s integrity, forcing it to take political sides. These Marxists hobble businesses like mobsters break kneecaps. Aviation is being targeted in this way by using our own people against us. The punchline is that Marxists will never respect those who surrender.

Many people view collaborating with and adopting Marxist ideologies, e.g., defunding law enforcement; attacking emergency services; the dissolving of Immigration and Customs Enforcement (ICE) and dismantling of the military, as un-American, as a very real threat to our society. Many leaders of different races say that Diversity is not an American problem; professional women are distancing themselves from those who would undermine commerce and society. Are ‘woke’ businesses really standing up for Diversity … or are they kneeling to anti-Americans? What is the endgame here? Do any that deflect adverse attention towards the Military, Law Enforcement and ICE, do they deserve the support of the American people? Should alumni support schools that stir unnecessary division? Should goods and services providers who promote anti-America propaganda deserve to be patronized? If they would stand by and not support our protective services, should they be supported?

Aviation is not given to selfish agendas, petty politics or fabricated emergencies. Aviation is given to professionalism born of experience, of skill. It is dependent on entrepreneurism, competition, safety and growth. Government’s only place in aviation is to provide oversight and assure safety, not dictate how imaginary social justice should be meted out or how the aviation community conducts business. There is something inherently wrong when those we trust to improve aviation, purposely confuse issues and compromise our integrity, all the while treating us as fools. Aviation is all about people, regardless of race, gender or status, doing their best for all people. We must not allow our attention or dedication be divided by those whose political agendas undermine us.

Aircraft Accidents and Lessons Unlearned LII: Eastern Airlines Flight 980

Mount Illimani with La Paz in the foreground Picture by Donald

On January 1, 1985, Eastern Airlines flight 980 (EA980), registration number N819FE, a Boeing 727-225A crashed at 2040 (8:20 PM) local time while descending towards a landing at La Paz airport in Bolivia. The aircraft impacted Mount Illimani at the 19,700-foot height mark; the aircraft was destroyed by impact forces.

A file (the only one found) of the Bolivian accident report, ‘Eastern%20980%20and%20Letter.pdf’ included Appendix A: a November 5, 1985, Letter to the NTSB Chairman; Appendix B: the Republic of Bolivia Ministry of Aeronautics report and Appendix C: the safety recommendations of Captain Don McClure. The Bolivian report in Appendix B stated, “… since the cockpit voice recorder [CVR] and flight data recorder [FDR] could not be recovered because of bad weather conditions and the inaccessibility of the terrain, the conclusion of this report has not been fully confirmed.” This statement was important as, among other reasons, the National Transportation Safety Board (NTSB) planned to get the FDR and CVR recorders at a later date.

The accident investigation and its subsequent report were accomplished and prepared by the Comision Investigadora de Accidentes e Incidentes de Aviacion (Board of Inquiry on Aviation Accidents and Incidents) of the Direccion General de Aeronautica Civil (Civil Aeronautics Bureau). The EA980 accident was assigned NTSB Accident Identification number DCA85RA007. Per the NTSB website, the foreign authority – Bolivia – was the source of accident report information. There was no NTSB docket information.

Working from air traffic control recordings of communications between EA980 to both Santa Cruz and La Paz control, the events that led to the accident were adequately pieced together. EA980’s last transmission: “La Paz, EA980 leaving flight level 250 [25,000] for 18,000 at this time,” was normal, relaying no sense of urgency or confusion from the flight crew. There was no reason to question that EA980 impacted Mount Illimani without an emergency taking place; EA980’s course, as discovered by post-accident analysis, had deviated twenty-six degrees from the assigned approach, which would account for the aircraft wandering into a course that would align with the mountain’s location.

In absence of any conflicting information, the aircraft hit terrain; given the time of night and the lack of identifiable landmarks, it is clear the flight crew became either disoriented or they intentionally veered away from the assigned flight path. No emergency calls or desperate transmissions, the aircraft, which was mechanically sound, had likely flew a controlled flight into terrain. This was a practical answer; the loss of recorders and survivors would not contradict this possibility.

Yet, Mount Illimani is a sizable land mass; would the flight crew have not seen it? Eastern 980 may have had a similar disadvantage as the Titanic, in that meteorological and astronomical conditions may have assisted in dooming the flight. With the Titanic, the calm sea and the dark of night hid the iceberg from view until the last moment. Could something similar have happened to Eastern 980?

Through the report, there is no reference to Lunar illumination, such as if the Moon was ‘out’, what time the Moon was seen and at what phase it was in. On January 1, 1985, the Moon was in Waxing Gibbous; this phase of the Moon appears from daytime to early evening and its brightness is from 59% to 99%, depending on what point of the Waxing Gibbous phase it was in. If the Moon was overhead, it might have provided an adequate illumination on the terrain below. However, the Moon would have been close to or below the horizon during EA980’s last minutes.

Were there adequate ground lighted references, e.g., cities, towns or highways for the crew to get a visual reference. It is unclear, but unlikely that in this part of Bolivia, these types of illuminations would have been enough to aid the flight crew in their situational awareness. Would Mount Illimani have suddenly ‘appeared’ as Eastern 980’s lights painted it? Were the B727 aircraft’s Krueger flaps even extended past five degrees, allowing the wing lights to point forward or were the wing root lights illuminated? Not likely as EA980 had not reached the point in its approach to run the landing checklist. The B727’s landing lights were most likely off.

What was the weather like? Did meteorological conditions hamper EA980’s flight crew by blotting out any celestial illumination from the sky, perhaps a starfield behind Mount Illimani or even the descending Moon? The accident report stated that, per La Paz control on January 1, 1985, the following weather was at the La Paz field: “La Paz 080/12 unlimited, 3SC500 iCB750-3AS2400-07/04 QNH millibars 1034 inches 30/53. Cumulonimbus SE of airfield.” Several pilots familiar with reporting international aviation weather were consulted, but the language of this transmission has changed since 1985; it was unclear what conditions were above 12,000 feet. However, EA980’s last weather report reflected the weather on the La Paz airfield, not where EA980 was flying near Mount Illimani. In addition, investigators believed EA980 drifted off course to avoid flying through inclement weather.

Finally, had the flight crew turned on the interior lights, thus eliminating their night vision? Was the pilots’ night vision compromised by the instrument lights enough to nullify any possibility of discerning shapes outside the windscreen? If they looked out, could they have separated Mount Illimani’s silhouette from the inky blackness of dark? It is reasonable to conclude that EA980 flew a controlled flight into Mount Illimani; that is a practical conclusion, almost impossible to disprove. Any responsible organization would have accepted the logic of that probable cause.

In Appendix C, Captain McClure retraced each leg of EA980’s accident flight plan and provided several observations and recommendations, based on his flying experiences and familiarity with La Paz. He gave insight into cultural and procedural problems that he felt contributed to unsafe practices that led to the flight 980 confusion as well as concerned him regarding ground crew practices. It was unclear whether any of Captain McClure’s recommendations were acted upon, indeed even added to the accident record.

It was the Appendix A letter that was most confusing. Among the items found in the Google search was a letter allegedly written nine months after the accident, outlining an attempt by inexperienced climbers to find the CVR and FDR recorders. To be clear, for professional climbers to ascend Mount Illimani to rescue survivors would have been a noble effort. However, EA980’s impact was too catastrophic; there never were any survivors to save; this fact was known within hours of the accident. To recover the deceased and/or their effects, an effort, though well-intentioned, would have been fool-hardy, even for the most experienced climbers; it would have had to be weighed against the risk – by professional climbers. Would the ends have justified the means? The odds for costly loss of further lives might have outweighed the benefits. There were no survivors, no effort would have changed that.

The letter to the NTSB Chairman, written by the field NTSB investigator who made the climb to the 19,700-foot level of Mount Illimani, detailed how he led a team of other inexperienced climbers to recover the recorders. The undertaking was hampered by team members’ health issues, equipment problems, food and water problems and other necessities, such as adequate shelters not being available during the ascent. The field investigator explained how he researched his ‘training’, “… about high-altitude mountain climbing so as to be well informed on the physiological factors associated with the high altitude and lack of oxygen.” Research? Why not hire experienced climbers or take a qualified climber with the team? The climb, as executed, was accomplished with arrogant inexperience.

If a ‘lack of oxygen’ affected one’s reasoning, then oxygen deprivation was present in the meeting that led to the expedition. It would have been incumbent on NTSB management to terminate any plans by this or any NTSB investigator from attempting something so foolhardy, but even NTSB management could not be depended on to do their jobs and stop such an unsafe venture.

Then there was the recorder recovery. The field investigator made it to the accident site, only to be defeated by a basic lack of knowledge of where the recorders were in the fuselage. Recorders are found in the rear of the aircraft, but their exact location can vary from operator to operator. For instance, a cargo operator may have the recorders located in the aft airstair while a passenger operator might have located them in a belly cargo hold, overhead bin or at the aft bulkhead. It was clear from the letter that the field investigator did not know where in the airplane the recorders were.

It is discouraging to read about these exploits and to accept that personal safety was not at the forefront of NTSB investigations; I would hope that NTSB field investigators today do not follow such foolish actions but accomplish their jobs safely with common sense dictating their actions – not government bureaucrats and employers of mismanagement. Not all accident sites are accessible, whether because of a lake’s depth, a mountain’s summit or the threat of carnivorous wildlife, no recovery of evidence is worth more lives to acquire. When I investigated the LAS DC-9 accident outside Mitu, Colombia, I did not drop into the jungles occupied by the drug cartel to recover evidence; the Colombian Army did with support aircraft and trained experts. That is common sense.

The Eastern Airlines flight 980 accident was tragic. Was it preventable? Most likely. It certainly was not intentional; there was no action taken by air traffic or the flight crew to misdirect the B727 into the mountain. To be clear, ‘preventable’ is often a hindsight view; we often cannot see far enough to prevent something unless it is clear what we are doing is wrong. Past successes (prior flights into La Paz) lull us into a false sense of security where we cannot see the forest for the trees. That is why we must get it right. But it also means that we learn from the best root cause possibilities. Could we prove, beyond a shadow of a doubt, that Eastern 980 was a controlled flight into terrain? No. But the NTSB could have allowed the assumption to dictate safety procedures to prevent controlled flight into terrain, nonetheless. And perhaps, they should have given Captain McClure’s recommendations another look.