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Robert E. Scovill JR |
Ms. Carol J. Carmody, Vice Chairman and Acting Chairman National Transportation Safety Board |
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Subject: |
This affidavit is submitted to the National Transportation Safety Board (NTSB) pursuant to Title 49 of the Code of Federal Regulations (CFR) part 845 section 51 (cite: 49CFR845.51): Investigation to remain open. Accident investigations are never officially closed but are kept open for the submission of new and pertinent evidence by any interested person. ... |
And pursuant to Title 49 (CFR) part 845 section 41 (cite: 49CFR845.41) petition is hereby made for reconsideration or modification of NTSB's findings and determination of probable cause for aircraft accidents involving general aviation aircraft equipped with Cessna Integral Wing Tanks. Based on new evidence, this petition seeks reconsideration or modification of relevant aircraft accident reports where engine failure or a rough running engine occurred and a probable cause is given as weather (such as carburetor ice), inadequate aircraft preflight or undetermined. |
References: Letter R1 to NTSB Chairman Jim Hall dated June 5, 2000 from Robert E. Scovill Jr., Smyrna, Tennessee. Letter R2 to Robert E. Scovill Jr.; Smyrna, Tennessee dated July 13, 2000 from NTSB Chairman Jim Hall FAAR3 Safety Recommendations 99.283 and 99.284 Letter R4 L417-02-01-105 to the Federal Aviation Administration (FAA) dated April 11, 2001 from Cessna Aircraft Company |
Dear Chairman Carmody: Previously, I submitted the matter of this affidavit to the NTSB in the letter to former NTSB Chairman Jim Hall mentioned in the above references. That letter was submitted as a safety recommendation for NTSB's consideration. The current letter is a petition submitted to the NTSB for consideration of using new evidence to reconsider the aircraft accidents that are listed further below. To my knowledge, this affidavit is the first formal petition to address topics that have not been submitted for the relevant aircraft accidents as proposed findings in accordance with 49CFR845.27. Thus, in accordance with 49CFR845.41, the subject of this affidavit qualifies as a formal petition to be entertained by the NTSB. |
This petition is submitted in the spirit of 49CFR831 .4 Nature of investigation, which states that Accident and incident investigations are conducted by the Board to determine the facts, conditions, and circumstances relating to an accident or incident and the probable cause(s) thereof. These results are then used to ascertain measures that would best tend to prevent similar accidents or incidents in the future. |
Identification of the new matter: |
Attached1: Statement of George Erdel to Robert E. Scovill JR; Smyrna Tennessee dated August 28, 1998. |
Attached2: Affidavit as potential witness, Bill Allen, Facilities Manager for MTSU, including his report dated June 2, 1999 |
Attached3: Affidavit as potential witness, Matt Taylor, Director of Maintenance for MTSU including his report dated October 10, 1999 |
Attached4: Report by Robert E. Scovill, Jr. dated February 1, 2000. |
Attached5: Report number A-83-6, NTSB recommendations to FAA and FAA responses over the years 1983 to 1986. |
The first four (1, 2, 3, and 4) attached reports contain results from tests performed on Cessna's integral wing tanks (also called wet wings). The results substantiate that Cessna's integral wing tank design has an indicated design flaw that does not permit positive detection of fuel contamination during a properly performed preflight check. Furthermore, published preflight procedures for some aircraft (later models) equipped with Cessna's integral wing tank include shaking these aircraft's wing and dipping these aircraft's tail to cause fuel contaminants to flow to a wing's sump area for draining. Test results contained in one of the above reports indicate that these procedures appear unlikely to achieve the desired results. |
Cessna Aircraft Company's letter to the FAA, L417-02-01-105--obtained through FOIA and listed in the above references--addresses the above topics in the context of FAA Safety Recommendations 99.283 and 99.284. The letter indicates that Cessna Aircraft Company is working with the FAA to investigate Cessna's integral wing tank design. The FAA appears to be investigating the indicated design flaw from an aircraft certification perspective. The NTSB needs to investigate the indicated design flaw from an aircraft accident perspective. |
In light of the new evidence contained in the attached test reports, the NTSB aircraft accident reports contained in this petition should be examined, and if appropriate, reconsidered for modification to reflect in NTSB's aircraft accident database that the indicated design flaw and published preflight procedures are probable causes. |
Affidavits of Prospective Witnesses |
Two prospective witnesses of the new evidence have provided affidavits for this petition. Their affidavits and reports by them that substantiate the new evidence are attached. |
Prospective witness: Bill Allen, Facilities Manager for MTSU |
Other Attachments |
Attached6: A Recommended Method for Examining Aircraft Accidents Listed in this Petition: Examination of NTSB's CHI92FA020 Report |
Why the new matter was not available prior to the Board's adoption of its findings. |
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1. |
It appears that some NTSB investigations of aircraft accidents involving aircraft equipped with Cessna's integral wing tank may not have explored the possibility that the wing tank design and published preflight procedures for it could have been contributing factors or probable causes. The reason for not investigating the wing tank design and preflight procedures may be due to inadequate NTSB investigation procedures or NTSB investigator's lack of experience with these types of aircraft accidents. This petition includes a table of aircraft accident reports by NTSB number involving aircraft that are not integral wing tank equipped. These reports raise questions about NTSB investigating procedures that appear to be subject to overlooking substantial and obvious clues that if properly examined could lead investigators to the discovery of other factors and other probable causes. The additional aircraft accident reports are included for the purpose of comparing investigating procedures found in aircraft accident reports involving aircraft equipped with Cessna's integral wing tank, which also raise questions about inadequate investigation or inadequate investigation procedures. |
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2. |
Historically, the NTSB has issued safety recommendations to the FAA regarding a lack of positive detection of fuel contamination that involved other fuel tank designs such as Cessna's rubberized bladder-type fuel cells. These safety recommendations are documented in the attached Report number A-83-6 in NTSB recommendations to FAA and FAA responses, which were written over the period May 24, 1983 to March 26, 1986. These safety recommendations are significant because they address the same indicated problem, lack of positive detection of fuel contamination, found in Cessna's integral wing tank and published preflight procedures. It isn't clear why the NTSB has not made use of its experience with these safety recommendations to relate similar subject matter. |
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3. |
Compounding the problem for NTSB's ability to recognize the indicated design flaw in its investigations is that throughout the general aviation industry emphasis is placed upon prevention of fuel contamination while detection of it is seemingly downplayed. Regardless of the measures taken to prevent fuel contamination, one must ultimately have a means to detect if prevention has occurred. Without a means for positive detection, no one can know if fuel contamination has been prevented or not. Preventive measures are important, but for the matter at hand, prevention is not the only issue. The issues are positive detection of fuel contamination and positive detection of prevention. It appears that the NTSB's attention has been focused too much on prevention. Turning attention to the topic of positive detection, the NTSB may find clues that justify reconsidering the aircraft accidents contained in this petition. |
Grounds Relied Upon |
This petition requests that the NTSB reconsider and modify, as appropriate, aircraft accident reports involving integral wing tank equipped aircraft that have probable causes from weather (such as carburetor ice), inadequate aircraft preflight or undetermined. Grounds for doing so are based upon the evidence presented that positive detection of fuel contamination is not assured. A pilot who performs a sufficient preflight check using published preflight procedures on the relevant aircraft system design can be potentially mislead to believe that fuel contamination does not exist when in fact it does. A need to emphasize positive detection is grounds for the NTSB to promote aviation safety by communicating in aircraft accident reports that positive detection of fuel contamination or positive detection of successful prevention of fuel contamination is necessary. |
Additionally, it is mandated under law that the NTSB use the results of its reports to ascertain measures that would best tend to prevent similar accidents or incidents in the future. The reports listed in this petition indicate that whatever it is that the NTSB is doing to ascertain measures ... to prevent similar accidents or incidents is not working because similar accidents continue to occur. |
The probable causes of primary interest for reconsideration are weather related causes (such as carburetor ice), inadequate aircraft preflight and undetermined. |
For the weather-related probable causes, carburetor ice or conditions conducive to carburetor ice are sometimes stated as the probable cause for a loss of engine power, engine failure, rough-running engine or a hesitating engine. These weather probable causes are at best likely but uncertain. How likely or how uncertain is usually implied by the conduciveness of icing as shown on an icing chart and mentioned in a report's narrative. Given knowledge of the new evidence, it appears that for some of the relevant aircraft accidents that icing due to weather is no more likely than fuel contaminated with water. In reconsidering aircraft accidents with probable causes attributed to weather, the NTSB must consider if an investigator made an attempt to determine if fuel contamination was a factor. It is possible, like ice, that a hazardous quantity of water from contaminated fuel was not visible in an investigation. Additionally, it is possible that an investigator used published procedures to take a fuel sample, which according to the new evidence is an unreliable means for detecting fuel contamination. Consequently, in the interest of aviation safety, relevant aircraft accident reports with weather related probable causes should be reconsidered and modified in light of the new evidence. |
For the pilot related probable causes, a NTSB investigator evidently, like most pilots, relies on the proper functioning of aircraft systems and published preflight procedures to measure the sufficiency of a preflight check. In light of the evidence presented, the NTSB needs to review its investigating procedures, methods and techniques for determining the sufficiency of a preflight check performed on relevant aircraft. If an investigation does not include investigating aircraft systems and published procedures that are factors in a pilot's preflight check, then the investigation is insufficient due either to inadequate investigating procedures or an investigators lack of total experience investigating the type of aircraft accident involved. Relevant aircraft accident reports with pilot related probable causes should be reconsidered with a focus of attention upon aircraft systems and the corresponding preflight procedures. |
For undetermined probable causes, the Board should review relevant reports to determine if the new evidence is applicable. |
NTSB's reconsideration should examine all factors related to fuel contamination including aircraft systems and preflight procedures used to detect it. |
Aircraft Accident Reports for Reconsideration |
The table on the following page contains fifty-seven NTSB Numbers that are believed to be accidents involving aircraft equipped with Cessna's integral wing tank, but this determination is difficult to make. Therefore, the NTSB should use whatever resources it has to determine which of the following reports involve aircraft that are integral wing tank equipped, and examine them for reconsideration under this petition. |
Aircraft Accidents by NTSB Number for Reconsideration |
ANC88LA149 |
DEN00LA091 |
LAX91LA381 |
ATL85MA286 |
DEN84FA012 |
LAX92LA062 |
ATL86LA252 |
DEN86FA092 |
LAX92LA387 |
ATL88LA071 |
DEN87LA141 |
LAX97LA038 |
ATL95LA048 |
DEN87LA210 |
LAX99LA314 |
ATL97LA099 |
DEN99LA174 |
MIA90LA048 |
ATL99LA042 |
FTW86FRG17 |
MIA92LA133 |
ATL99LA062 |
FTW90LA082 |
MIA94LA014 |
BFO94LA024 |
FTW92LA097 |
MIA97LA083 |
BFO95FA028 |
FTW94LA107 |
MIA97LA118 |
CHI84LA103 |
FTW95TA187 |
MKC85FPG02 |
CHI84LA147 |
FTW98LA349 |
MKC85LA188 |
CHI85LA066 |
FTW99LA141 |
MKC90FA044 |
CHI86FEV01 |
IAD96LA123 |
NYC00LA024 |
CHI92FA020 |
LAX83FA122 |
NYC85FA120 |
CHI92LA056 |
LAX88LA063 |
SEA91LA001 |
CHI92LA073 |
LAX88LA289 |
SEA91LA009 |
CHI92LA111 |
LAX89LA323 |
SEA92LA068 |
CHI94LA075 |
LAX91FA081 |
SEA95LA182 |
The tables that follow on this page and the next contain 194 NTSB numbers for aircraft accident reports that contain information that raises questions about NTSB's investigating procedures. A review of these reports that focuses on possibly overlooked clues for factors and probable causes during an investigation reveals a substantially strong need for NTSB to evaluate its investigation procedures for general aviation aircraft. The NTSB can use the results of such a review to ascertain measures such as examining the above aircraft accident reports involving integral wing tank equipped aircraft searching for possibly overlooked clues that point to other factors and probable causes for reconsideration. Modifying relevant reports to correctly indicate where dangers exist in aircraft systems, preflight procedures and aircraft accident investigating procedures will be a step that best tends to prevent similar accidents. For the sake of safety, the following 194 NTSB aircraft accident reports are in urgent need of answers to some alarming questions. |
Aircraft Accidents by NTSB Number for Review |
ANC85LA058 |
CHI92LA112 |
LAX93LA072 |
ANC86FA035 |
CHI94LA085 |
LAX94LA277 |
ANC86LA004 |
CHI95LA110 |
LAX96LA071 |
ANC87LA160 |
CHI97LA068 |
LAX97LA080 |
ANC88LA034 |
CHI98LA147 |
LAX99LA159 |
ANC90FA040 |
CHI98LA255 |
MIA87FA217 |
ANC90LA175 |
CHI98LA335 |
MIA88FA187 |
ANC91IA039 |
CHI98LA348 |
MIA89LA084 |
ANC92LA019 |
CHI99LA336 |
MIA95LA165 |
ANC94LA121 |
DEN00LA059 |
MIA96LA137 |
ANC96LA029 |
DEN84LA147 |
MIA97LA230 |
ANC97LA153 |
DEN84LA229 |
MIA98LA093 |
ANC98LA064 |
DEN85LA249 |
MIA98TA011 |
ANC98LA075 |
DEN87LA150 |
MIA99LA171 |
ANC99LA052 |
DEN89LA054 |
MKC84LA013 |
ANC99LA096 |
FTW00LA115 |
NYC00LA203 |
ANC99LA126 |
FTW86FRA01 |
NYC88LA030 |
ATL88LA100 |
FTW88LA059 |
NYC90LA037 |
ATL88LA216 |
FTW90LA057 |
NYC93LA048 |
ATL89LA050 |
FTW92LA071 |
NYC95LA067 |
ATL93LA095 |
FTW93LA031 |
NYC95LA135 |
ATL94LA175 |
FTW94LA051 |
NYC98LA042 |
ATL99LA099 |
FTW94LA083 |
NYC99LA156 |
BFO85LA069 |
FTW94LA173 |
SEA93LA103 |
BFO95LA069 |
FTW95LA295 |
SEA94LA023 |
CHI84LA008 |
FTW96LA166 |
SEA95LA040 |
CHI84LA168 |
FTW98LA061 |
SEA95LA208 |
CHI86FER07 |
FTW99LA070 |
SEA97LA151 |
CHI87LA078 |
IAD97LA093 |
SEA99LA078 |
CHI90LA163 |
LAX88LA201 |
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CHI91LA148 |
LAX92LA125 |
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ANC96LA031 |
CHI99FA052 |
LAX99LA267 |
ANC96LA047 |
CHI99LA069 |
MIA00FA201 |
ANC99LA034 |
CHI99LA082 |
MIA00LA076 |
ATL00FA061 |
DEN01LA011 |
MIA00LA099 |
ATL01FA059 |
DEN88LA082 |
MIA00LA100 |
ATL01LA009 |
FTW00LA036 |
MIA00LA127 |
ATL01LA017 |
FTW00LA071 |
MIA00LA162 |
ATL01LA028 |
FTW00LA182 |
MIA00LA238 |
ATL01LA052 |
FTW00LA248 |
MIA95LA161 |
ATL88LA156 |
FTW01FA014 |
MIA96LA188 |
ATL95LA121 |
FTW01LA078 |
MIA96LA194 |
ATL97LA037 |
FTW01LA146 |
MIA97LA033 |
ATL97LA120 |
FTW88LA061 |
MIA97LA064 |
ATL99LA034 |
FTW90LA050 |
MIA97LA224 |
ATL99LA056 |
FTW96FA108 |
MIA98LA030 |
BFO88FA022 |
FTW98FA024 |
MIA98LA249 |
CHI00LA046 |
FTW98LA091 |
MIA99LA135 |
CHI00LA241 |
FTW98LA204 |
MKC88LA081 |
CHI00LA245 |
FTW98LA210 |
MKC90LA046 |
CHI00LA261 |
FTW98LA357 |
NYC00LA070 |
CHI00LA311 |
FTW99LA008 |
NYC00LA223 |
CHI01FA085 |
FTW99LA058 |
NYC00LA262 |
CHI01LA068 |
FTW99LA064 |
NYC01LA149 |
CHI01LA074 |
FTW99LA066 |
NYC88LA077 |
CHI01LA170 |
FTW99LA185 |
NYC88LA118 |
CHI01LA196 |
FTW99LA205 |
NYC90LA044 |
CHI83LA087 |
IAD01LA037 |
NYC90LA055 |
CHI93LA049 |
IAD96LA060 |
NYC96LA088 |
CHI96LA128 |
IAD96LA065 |
NYC96LA096 |
CHI97LA037 |
LAX01FA198 |
NYC97LA049 |
CHI97LA172 |
LAX84LA179 |
NYC98LA037 |
CHI97LA179 |
LAX96LA151 |
NYC98LA078 |
CHI97LA276 |
LAX97LA033 |
SEA98LA022 |
CHI98LA131 |
LAX97LA129 |
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CHI98LA226 |
LAX99LA034 |
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This petition encourages the Safety Board to evaluate the evidence presented and reconsider the issue of positive detection with the same urgency expressed in its safety recommendations to the FAA over the years 1983 to 1986. In the current year, 2001, a response from the NTSB to the public about the possibility that fuel contamination may be a contributing factor where probable cause has been routinely reported as weather or undetermined suggests that the NTSB is not treating matters with the urgency needed. |
For example, the following excerpt is taken from the article Drainage Flaws Suspected in Cessna Fuel Tanks (2/21/2001. © Flyer Media, Inc.) by James Wynbrandt. |
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Scovill [the petitioner] said he also suspects that water contamination plays a larger role in fuel-starvation accidents than investigators realize. He suggests that fuel contamination may actually cause accidents where the NTSB has attributed engine failure to an "unknown cause" and where carburetor ice has been suspected as a contributing factor. |
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When asked about that possibility, NTSB spokesman Keith Halloway said, "We don't discuss hypotheticals. Unless we're conducting an investigation on a particular issue, we don't like to speculate or give any false leads to anything." |
In the letter from former Chairman Jim Hall dated July 13, 2000 written to the petitioner and cited further above under references to this petition, Hall states the following. |
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The Safety Board appreciates your safety concerns and has contacted the Federal Aviation Administration (FAA) to discuss this issue. The board has verified that the FAA has developed and is implementing a plan to determine if the integral wing fuel tanks of Cessna high-wing, single-engine airplanes comply with applicable certification standards. Board staff will carefully monitor the FAA's progress to ensure that appropriate actions are taken. In addition, all Board personnel tasked with investigating general aviation accidents will be made aware of the possibility that water contamination in the integral wing fuel tanks of Cessna high-wing, single -engine airplanes may not be detectable during preflight inspections. |
I hope that the Safety Board's disposition on the safety matters discussed in this petition is not reflected in Halloway's statement that the issues are hypothetical. The attached test results are real. The aircraft accident reports in NTSB's database are real. FAA Safety Recommendations 99.283 and 99.284 are real. Title 49 CFR831.4 and Title 49 49CFR845.41 are real. Furthermore, Halloway's use of the words Unless we're conducting an investigation on a particular issue implies that the issues do not have NTSB's attention, which seems contrary to former Chairman Hall's response to me. |
Finally, it is appropriate to expect that spokespersons for the NTSB will possess a higher command of the English language than the general public to whom they speak. In their professional capacity as spokespersons, these people are paid to convey useful information to the public. The Safety Board should consider if Halloway's attempt to inform the public is representative of the professionalism that is normally associated with the NTSB. |
Halloway said, "Unless we're conducting an investigation on a particular issue, we don't like to speculate or give any false leads to anything." |
I suggest that the NTSB scrutinize the above statement. If NTSB aircraft accident reports relevant to this petition are examined with the same scrutiny, the Safety Board will find that the safety issues presented are real, not hypothetical. |
I conclude this petition with a request that the NTSB informs me of how best to correspond with the Board regarding the details of the topics presented. I am prepared to discuss relevant aircraft accident reports one at a time, or as a group, either verbally or in writing. I eagerly await the Board's response. |
Sincerely yours,
Robert E. Scovill JR Petitioner |
Attachments |
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Statement of George Erdel to Robert E. Scovill JR; Smyrna Tennessee dated August 28, 1998. |
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Affidavit as potential witness, Bill Allen, Facilities Manager for MTSU, including his report dated June 2, 1999. |
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Affidavit as potential witness, Matt Taylor, Director of Maintenance for MTSU including his report dated October 10, 1999. |
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Report by Robert E. Scovill, Jr. dated February 1, 2000. |
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Report number A-83-6, NTSB recommendations to FAA and FAA responses over the years 1983 to 1986. |
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A Recommended Method for Examining Aircraft Accidents Listed in this Petition: Examination of NTSB's CHI92FA020 Report |
Table of Contents for aircraft accident reports included in the petition. |
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