After leaving the aircraft and realizing that the engines were still running,. I immediately returned, pulling myself into the cockpit, and attempted by alternative means to shut down the engines and prevent fire. Meanwhile, the First and Second Officers helped passengers from the wing and rendered all possible assist-ance to the passengers considering the circumstances. Inside the cockpit, I was unable to stop the engines, but I was able to get the cockpit door open, backwards! The door had obviously been jammed. In my super adrenalized state I was able to free one Flight Attendant from a coat closet and other debris which had collapsed on her. I then assisted her and another Flight Attendant to exit the aircraft through the cockpit windows. I was the last person to leave the aircraft. The Board cited the cockpit crew's failure to go to our evacuation stations according to procedures. In addition to failing to properly assess all of the aforementioned circumstances, the Board does not seem to understand that accidents rarely happen according to plan. Procedures do not supplant good. judgement. With all 124 passengers in the aisle clamoring for the exits, how is it possible for the Second Officer to proceed to the aft cabin? In the NTSB's Safety Recommendation A-76-76, the Board stated that "Although the available wind information indicated. . . Continental 426 used normal procedures which included a noise abatement climb profile." The inference that there is an option which may have produced different results is uninformed and misleading. All of the climb profiles are identical to 400 feet. Flight 426 did not get over 150 feet. The inference also indicates that the Board saw fit to diverge from the aircraft manufacturer's conclusion where Boeing stated that under the circumstances encountered by Flight 426, the aircraft could not sustain flight. I don't believe that airline pilots are beyond criticism, but I do believe that unjust criticism can be very harmful. In this case, the harm is not only to Continental Airlines, my crew and myself, but to the very heart of the NTSB's goal to promote safer transportation. If the airline pilot and the airline do not have confidence in the ability and judgement of the Board, then they will pay only superficial attention to the Board's findings and recommendations. All of us in the industry do our best to promote safety on our own, but the additional thrust of the NTSB will be lost without technical competence equal to the complexity of this industry. [The following information was subsequently received for the record:] Hon. HOWARD W. CANNON, Chairman, Committee on Commerce, AIR LINE PILOTS ASSOCIATION, Los Angeles, Calif., July 1, 1976. Subcommittee on Aviation, U.S. Senate, DEAR MR. CHAIRMAN: This letter is supplemental to my letter of June 25, 1976 relating to the NTSB investigation of Continental Airlines Flight 426 which crashed in Denver, Colorado, on August 7, 1975. Subsequent to writing the letter of June 25, the full NTSB report on this crash has been published. One paragraph in particular at the top of page 29 of this report is very pertinent: "Since there was no evidence that the cockpit door was jammed or otherwise inoperable, the Safety Board believes that the flightcrew made little effort to proceed to their evacuation duty stations in the passenger cabin. Instead, the evidence indicates that the flightcrew abandoned the cockpit through the sliding windows as rapidly as possible. The Safety Board concludes that the flightcrew's performance in this respect did not conform to the standards of professional crewmembers." The evidence proves just the opposite. Consider the following and there couldn't be any doubt: 1. The door normally opens aft into the passenger cabin but it was found in the cockpit. I opened it backwards against the door stops. 2. The coat closet which is located just aft of the cockpit door had collapsed against the back of the door. Two men were unable to move the closet after the crash. 3. All of the contents of the coat closet were heaped against the door. When I opened the door one of the Flight Attendants was literally buried under garment bags and debris. 4. The Second Officer testified that he thought he had tried the door and was unable to open it. 5. The attached letter from one of the passengers totally supports the facts that the door was jammed. The baggage compartment referred to in his letter is what I have referred to as the coat closet. It is difficult to imagine why these facts were not brought out by the Board. I do know, however, that a Mr. LeRoy was in charge of the Human Factors Investigation on behalf of the NTSB and somehow he neglected to interview any of the cockpit crew members. After reading the entire NTSB report, I believe that the Board's impression of the "standard of professional crews" would be the standards fashioned by a Hollywood education. After nearly unlimited physical and emotional abuse they seem to expect the flight crew to sacrifice their own lives even when it appears that they are helpless to assist the passengers. That may make good press, but frankly I won't ride with a pilot whose judgment is that far out of touch with reality. The Board's criticism of myself, the First and Second Officer's performance during the evacuation implies among other things a selfish act of cowardice. This is particularly grating since all three of us were combat military pilots, an occupation which takes a lot more character than what the Board gave us credit for. I can only conclude that the Board is too idealistic and far removed to recognize what it is like to go through an experience like this for real. I do not think competent aviators will concur with the Board's judgment. Sincerely, Attachment. Mr. WEBSTER B. TODD, Jr., Chairman of Transportation Safety Board, CAPT. ROBERT E. PRIES, DENVER, COLO., June 16, 1976. DEAR MR. TODD: It was with dismay and surprise that I read of your board's decision to criticize the crew of Continental Airlines Flight 426 which was involved in an incident at Stapleton International in Denver on August 7, 1975. As an eye witness and passenger on that flight I must say that not only was your criticism of the flight crew uwarranted, but probably if it had not been for their expertise in handling the aborted takeoff, the ultimate results could have been worse-indeed a catastrophe. As I told your investigators, because I was a passenger in the front cabin, I was probably the first or second person to reach the lefthand door on the aircraft through which we had all entered. It was and is still my testimony that the baggage compartment was blocking not only the main door of the aircraft but also the cockpit door and had trapped two cabin attendants against the bulkhead. It is therefore perplexing to me that you should criticize the crew for not coming directly into the first class cabin. I realize at this particular point that my personal observations will not change your bureaucratic decision, however, I would like to publicly thank the crew for what I thought was superior performance and I, for one, appreciated the way they responded to the pressures of the day. Sincerely, DAVID E. BAILEY. Captain O'DONNELL. Thank you very much, Mr. Chairman. Some have suggested that the criteria we recommend for Board eligibility are so narrow as to exclude anyone who is not an experienced aviator. This erroneous interpretation of our position is unfortunate because it has the effect of distorting the real issue involved in NTSB appointments. What is most important is that the Board members have broad technical background and experience in transportation safety which will enable them to provide professional leadership to accident investigations in any one of the five modes which come under the Board's jurisdiction. We would like to suggest for your consideration three specific areas of experience which we believe should be a part of the background of any nominee for NTSB membership. (1) Industry experience or educational background in one of the disciplines dealing with physical or life sciences would be excellent preparation for providing proper direction to the Board in terms of analytic approach to accident investigations. (2) Operational experience in either military or commercial transportation would provide insight into the actual environment in which the accident occurs. (3) Recent experience with the highly complex interfacing between personnel and systems within the transportation industry would provide appreciation for and understanding of the significant safety factors involved therein. Mr. Chairman, we have thoroughly reviewed the educational and professional background of the nominee before you today, and it is our judgment that she has no experience in any of the areas enumerated above. But the issue before this subcommittee today is far more critical than the nomination of Kay Bailey. What is at stake here is the determination of the Senate to preserve the integrity of those provisions of the Transportation Safety Act of 1974 which encourage the appointment of members to the NTSB on the basis of technical qualification and professional or management standing in the field of accident reconstruction, safty engineering, or transportation safety. We commend you, Mr. Chairman, for your leadership in the enactment of this legislation designed to upgrade the level of technical and professional competence of the members of the NTSB. Such a law is in the public interest, and stands out as a model for other presidentially-appointed boards which must deal in technical subjects. But the job is not finished with the passage of a law. All of us who are vitally concerned about safety in transportation must be vigilant to insure that the legislative goal of this subcommittee and the U.S. Senate is fulfilled. This concludes my statement, and I will be pleased to respond to any questions, Mr. Chairman. [The attachments referred to follow:] Mr. WEBSTER B. TODD, AIR LINE PILOTS ASSOCIATION, Chairman, National Transportation Safety Board, DEAR DAN: As we have discussed, there are, on occasion, certain issues which we agreed should be called to your attention. The concerns occasioned by the information contained in the enclosed Petition for Reconsideration of the Board's probable cause findings in the PAA B-707 accident of January 30, 1974 at Pago Pago International Airport fall in that category. The ALPA air safety representatives have alerted me to the fact that not only was the Board's effort unsatisfactory on this particular investigation, but also that similar shortcomings are found with distressing regularity in other investigations. Specifically, the superficial utilization of the data contained on both the flight and cockpit voice recorders regularly renders suspect both the findings and recommendations of the Board. If the Board is to be effective in the accident prevention field and do more than simply assess blame, superficiality must be eliminated from the final product. The attached Petition clearly highlights the misapplication of the recorded data and illustrates a problem which recurs with far too great a regularity. Of even greater urgency is the almost total lack of concern for the human factors involved in accidents, such as the one in Pago Pago. Clearly, if human performance is a factor in an accident, the relevant facts are what the crew perceived as related to the actual situation. Only by exploration of these matters can there be any hope of arriving at recommendations which will prevent future accidents. Absent meaningful study in this very complex area, the Board will be unable to do more than continue to point the finger of blame. This makes it easy for the lawyers but a matter of dispair for those dedicated to accident prevention. It is our hope that through your leadership we can see a major effort by both Government and the industry to explore this largely uncharted area. Please be assured of ALPA's wholehearted support in any study efforts in the human factors field. If we can be of any assistance with regard to the information contained in the Petition, don't hesitate to call on us. Copies of this Petition are being forwarded to each of the parties to this investigation. Sincerely, Hon. WEBSTER B. TODD, J. J. O'DONNELL, President. AIR LINE PILOTS ASSOCIATION, Chairman, National Transportation Safety Board, DEAR MR. CHAIRMAN: Enclosed is a petition to the Board for modification of the probable cause or a reopening of the investigation of the Eastern Air Lines Douglas DC-9 accident which occurred near the Charlotte, North Carolina Airport on September 11, 1974. It is disappointing to note that this petition is based on essentially the same premise as the Pago Pago petition filed on May 6, 1976. Our analysis of the Board's Charlotte Report, compared to the information which was available but apparently ignored during the formulation of the Board's position, leads to the conclusion that once again superficiality clouds both the Findings and Recommendations of the Board. By way of illustration, the petition demonstrates that by diligently reading the voice recorder, it could be ascertained that the flight was conducted in a very professional manner (in contrast to the Board's inference that it was haphazard and unprofessional). Further, the flight recorder shows that the flight was handled in a precise manner up to the time that an altitude error occurred. By seizing upon the easy solution of charging the crew with inattention, the Board foreclosed the proper line of inquiry and, as a result, insured that its Report would be of little or no value in the all important area of accident prevention. It is difficult to understand why the Board, in its transcript of the voice recorder, excluded all three references to fatigue. Even a perfunctory inquiry into the Captain's flight schedule of the preceding nine days should have alerted those making the investigation that fatigue be considered, particularly when an otherwise professional crew performance deteriorated unexplainably with the apparent misreading of the altimeter by the First Officer and the Captain's failure to catch it in his backup capacity. The action by the Chairman of the Inquiry to exclude from the Hearing Record the FAA commissioned study on drum pointer altimeters is certainly questionable. The study demonstrates that 1,000-foot misreadings are typically induced by the instrument design. Also not mentioned in the Board's Findings was the fact that the altitude monitoring capability of the ARTS III was not utilized 75-802-76-3 and the absence of precision approach equipment on this air carrier runway may have been a contributing cause of the accident. Once again, we must solicit your assistance in providing a more objective analysis of this accident and, in particular, we must reiterate our concern that the human factors associated with this and many other accidents represent an important subject which has been ignored in the past by the NTSB. If we continue to overlook this subject area, we most assuredly are exposed to a repetition of tragedies such as this. For your information, we have transmitted a copy of the petition to each of the interested parties to review. Sincerely, J. J. O'DONNELL, President. Senator CANNON. Thank you, Mr. O'Donnell. Senator Pearson. Senator PEARSON. John, in all fairness, now, the criteria you have set out for technical qualifications are going to be pretty tough. This Board has jurisdiction over marine safety, rail safety, highway safety, and pipeline safety in addition to aviation safety. If we had to meet all of these kinds of industry experience, educational background, and operational experience in all of these fields, I don't think we'd get anybody to qualify for this Board. Do you think that's an unfair question to put to you? Captain O'DONNELL. Oh, no question from you, Senator, is unfair to me, but we feel, Senator, that the qualification Senator PEARSON. I know what you're trying to say, but I'm trying to say something, too. If you put these sorts of requirements down for qualification on a Board such as this, with such wide jurisdiction, moving from transportation mode to transportation mode, we really wouldn't find anybody to meet these criteria. I think it was the common denominator of opinion of the people who wrote this conference report, and agreed to it, that you have to have some technical qualifications. There isn't any question about that, but there needs to be some generalists there, too, some people with just plain good commonsense. Captain O'DONNELL. Well, we're not commenting on the commonsense of Kay Bailey. I've met Kay Bailey and Senator PEARSON. No; I know you're not. Captain O'DONNELL [continuing]. I think I announced earlier that I was very much impressed by her and Senator PEARSON. I understand the nature of your objection. Captain O'DONNELL. Yes, but the only thing is, Senator, there are several other agencies within the Government for which the President sends nominations to the Senate for confirmation, and we understand that the President solicits recommendations from professional organizations such as the American Society of Safety Engineers, to make sure the nominees are technically competent in the field that's under consideration. And that is something we think that perhaps the President should take into consideration when he comes up with nominess for such a highly technical subject as transportation safety. It was stated that only 3 percent of the accidents occur in aviation, but I would venture to say that about 80 to 90 percent of the NTSB time is spent in aviation accidents. And so our concern is, and we think the U.S. Senate expressed it in the legislation, that they wanted technically competent people. We think that the compromise between. |