Abstract
We regularly ask after the limits of historical inquiry; we agonize over the right combination of psychological, sociological, and technical explanations. We struggle over how to combine the behavior of machines and practices of their users. Imagine, for a moment, that there was a nearly punctiform scientific-technological event that took place in the very recent past for which an historical understanding was so important that the full resources of the American government bore down upon it. Picture further that every private and public word spoken by the principal actors had been recorded, and that their every significant physical movement had been inscribed on tape. Count on the fact that lives were lost or jeopardized in the hundreds, and that thousands of others might be in the not so distant future. Expect that the solvency of some of the largest industries in the United States was on the line through a billion dollars in liability coverage that would ride, to no small extent, on the causal account given in that history. What form, we can ask, would this high-stakes history take? And what might an inquiry into such histories tell us about the project of — and limits to — historical inquiry more generally, as it is directed to the sphere of science and technology?
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Notes
National Transportation Safety Board, Aircraft Accident Report, Air Florida, Inc. Boeing 737–222, N62AF, Collision with 14th Street Bridge, Near Washington National Airport Washington, D.C. January 13, 1982, p. 1–10. Hereafter, NTSB-90.
NTSB-90, p. 10.
NTSB-90, p. 22.
“Addendum to Aircraft Performance Engineer’s Factual Report of Investigation,” SA 477, 10 May 1982, AF 90 Docket: Exhibit I3-A, Fiche 19-A (hereafter, “E13-A, F19-A”); NTSB-90, pp. 26–27.
NTSB-90, p. 57.
NTSB-90, p. 58.
See e.g. “Other Factors Relating to Accident,” NTSB-90, pp. 68ff. for discussion of traffic spacing, runways at Washington National, 737 pitch-up characteristics, among others.
NTSB-90, p. 40.
NTSB-90, p. 64.
Van Sickle, Modern Airmanship (Tab: Blue Ridge Summit PA, 1990), p. 540.
“Operations Group Chairman’s Preliminary Factual Report,” DCA-82-AA-011, p. 8 (stamped 000017), AF 90 Docket: E2A, F 1.
NTSB-90, p. 75.
NTSB- 90, p. 40.
NTSB-90, p. 65.
NTSB-90, p. 70.
Robert Buck, The Pilot’s Burden (Ames: Iowa State University, 1994), p. 207.
See e.g. Peteris Galins and Mike Shirkey, “737 Wing Leading Edge Condition — Part II,” Boeing Airliner, Oct-Dec. 1981, p. 19 (stamped 001519), AF 90 Docket: E13-V, FI7: “Stall characteristics with both symmetric and asymmetric simulated frost were characterized by a very apparent pitch-up, yaw rate, and roll-off.” Also, NTSB-90, p. 66.
NTSB-90, p. 82.
Cited in United Airlines training manual, “Introduction to Command/Leadership/Resource Management,” MN-94, 10/95, p. 25.
National Transportation Safety Board, Aircraft Accident Report, Delta Air Lines, Inc., Lockheed L1011–385–1, N726DA, Dallas/Fort Worth-International Airport, Texas, August 2, 1985, NTSB/AAR-86/05, (Flight 191), hereafter, NTSB-191, p. 71.
Robert Helmreich, “Social Psychology on the Flight Deck,” in George E. Cooper, editor, Resource Management on the Flight Deck. Proceedings of a NASA/Industry Workshop Held at San Francisco, California, June 26–28, 1979, N80–22283, pp. 17–30.
Lee Bolman, “Aviation Accidents and the ‘Theory of the Situation,’” in ibid., pp. 31–58, on p. 40.
Stanley R. Trollip and Richard S. Jensen, Human Factors for General Aviation, (Jeppeson Sanderson: Englewood, CO, 1991), p. 9–8.
United Airlines, “Introduction,” MN-94, p. 13.
Ibid., p. 26.
Buck, Pilot’s Burden (1994), p. 207.
One of the widest-ranging accounts of the crash came from the Aviation Consumer Action Project (ACAP) that included Ralph Nader as Chairman of the Advisory Board. In their letter of 15 April 1982 to the NTSB (AF 90 Docket: F 19A), ACAP lambasted the pilots’ performance, the poor safety oversight by the FAA, Washington National Airport for its inadequate runways and rescue plans, the 737 for its susceptibility to icing, and Air Florida for its precipitous and poorly executed expansion.
Alfred Haynes, “United 232: Coping with the Loss of All Flight Controls,” in Air Line Pilot 55 (October 1991): 10–14, 54–55, this reference, p. 54; part II, (November 1991): 26–28.
“Operations Group Chairman’s Factual Report,” UAL 232 Docket: E2A, F2, p. 16 (stamped 175).
National Transportation Safety Board, Aircraft Accident Report, United Airlines Flight 232, McDonnell Douglas DC-10–10, Sioux Gateway Airport, Sioux City, Iowa, July 19, 1989 (hereafter, NTSB-232), p. 1.
NTSB-232, p. 22.
Ibid. p. 71, and Haynes, “United 232,” p. 11.
Haynes, “United 232,” pp. 54–55, and NTSB-232, pp. 21–23, 35–38; also interview by Operations Group with Second Officer Dudley Joseph Dvorak, 22 July 1989, UAL 232 Docket, Addition 1: E2D, Fl.
NTSB-232, p. 15.
NTSB-232, pp. 17–19, 32–35.
NTSB-232, p. 47; see also B. J. Moniz, Metallurgy (Homewood, Illinois: American Technical Publishers, Inc., 1992), 346–50.
NTSB-232, pp. 49–52.
NTSB-232, pp. 55–58.
NTSB-232, p. 80.
NTSB-232, p. 83.
NTSB-232, pp. 15, 77, 85.
NTSB-232, p.87.
UAL Final Report, 8 March 1990, “Conclusion 3.10.” UAL 232 Docket, Addition 5: item 1, FI.
NTSB-232, p. 88: As a result of the Aloha Airlines 737 crash in April 1988, the Safety Board forwarded two recommendations to the FAA that were relevant to maintenance: from A-89–56, “Require formal certification and recurrent training of aviation maintenance inspectors performing nondestructive inspection functions. Formal training should include apprenticeship and periodic skill demonstration.” In A-89–57 they asked for specific training programs that would require “operators to periodically test personnel on their ability to detect the defined defects.”
NTSB-232, p. 88.
NTSB-232, p. 85.
NTSB-232, pp. 89–90.
See e.g. figure 1 of FAA, Advisory Circular AC 25–2309–1A, “System Design and Analysis,” pp. 7ff, UAL 232 Docket, Addition I: E9H, F7.
Ibid., paragraph 10.
Airline Pilots Association Report, UAL 232 Docket, Addition 5: F 15.
Emphasis added, NTSB-232, p. 91.
Jim Burnett, dissenting opinion, NTSB-232, p. 109.
NTSB 232, pp. 72–73. The NTSB’s ‘Simulator Study-Initial Report’(17 October 1989) concludes by quoting the consensus of the test pilots who flew the simulator: “You could pick your touchdown position, direction, attitude, or vertical velocity. Achieving all desired conditions at the same time [was] virtually impossible” (UAL 232 Docket, Addition 1: E16C, FI1).
NTSB-232, p. 76, emphasis added.
Haynes, “United 232,” p. 14.
Buck, Pilot’s Burden (1994), p. 214.
“General Electric Aircraft Engineers Report,” 23 March 1990, UAL 232 Docket, Add. 5: Item 3, F3, p. iv.
“Airline Pilots Association Report,” 7 March 1990, UAL 232 Docket, Add. 5: Item 16, F15. In particular, the Airline Pilots Association pointed out that even if the likelihood of failure of all hydraulic pumps and their backups were one in a billion, such calculations would be irrelevant should some other factor cause the hydraulic fluid to be drained. Two such incidents had occurred in which all but one hydraulic line was drained, and in 1985 all hydraulic systems failed in the crash of a JAL jumbo jet which killed almost all aboard.
Under Section 702 of the Civil Aeronautics Act of 1938 (52 Stat. 1013, 49 U.S.0 582), the Civil Aeronautics Board is responsible for investigating aircraft accidents: “It shall be the duty of the Board to… (2) Investigate such accidents and report to the Authority the facts, conditions, and circumstances relating to each accident and the probable cause thereof… ”
Dumbra v. United States, 268 U.S. 435, 439, 441 (1925), cited in Wayne R. LaFave, Search and Seizure. A Treatise on the Fourth Amendment, Third Edition, Volume 5 Sections 11.1 to End, (West Publishing Co.: St. Paul, Minn., 1996), p. 1172.
Lock v. United States, 7 Cr. (11 U.S.) 339, 348 (1813), cited in LaFave, Search and Seizure (1996), p. 1172, note 9.
See International Standards and Recommended Practices Aircraft Accident Investigation Annex 13 to the Convention on International Civil Aviation. Seventh Edition — May 1988.
The NTSB also laid some contributing cause culpability to the FAA for inadequate supervision of the ATR planes. National Transportation Safety Board Aircraft Accident Report Volume I: Safety Board Report, “In-Flight Icing Encounter and Loss of Control Simmons Airlines, d.b.a. American Eagle Flight 4184. Avions de Transport Regional (ATR) Model 72–212, N401AM. Roselawn, Indiana, October 31, 1994. Volume 1: Safety Board Report, p. 210.
The Bureau laid its contributing causes at the feet of the crew, who, they contended, failed to exercise situational awareness, cockpit resource management, or standard sterile cockpit — and left some blame also for Airworthiness Authorities, Air Traffic Control, and to European and American, and ATR for not having investigated more fully Aileron hinge reversal in icing conditions. See ibid., Volume II: Response of Bureau Enqûetes-Accidents to Safety Board’s Draft Report, p. 266.
International Standards and Recommended Practices Aircraft Accident Investigation Annex 13 to the Convention on International Civil Aviation. Seventh Edition — May 1988, p. 18; and ibid, eighth edition, July 1994, p. 18.
Commission d’enquête sur l’accident survenu le 20 janvier 1992 à l’Airbus A 320 F-GGED près du mont Sainte-Odile (Bas-Rhin), rapport final. Journal officiel de la République Française, édition des documents administratifs.
Steven Cushing, Fatal Words. Communication Clashes and Aircraft Crashes (Chicago: University of Chicago Press, 1994).
Diane Vaughan, The Challenger Launch Decision. Risky Technology, Culture, and Deviance at NASA (Chicago: University of Chicago Press, 1996), e.g. pp. 34, 456ff.
James Reason, Human Error (Cambridge: Cambridge University Press, 1990). Interview with Barry Strauch, 1 April 1999.
Charles Perrow, Normal Accidents. Living with High-Risk Technologies (New York: Basic Books, Inc., 1984).
See e.g. Michel Callon, “Some Elements of a Sociology of Translation: Domestication of the Scallops and the Fishermen of St. Brieuc Bay,” and Bruno Latour, “Give Me a Laboratory and I Will Raise the World,” both reprinted in M. Biagioli, Science Studies Reader (New York and London: Routledge, 1999).
For a recent summary of views of Copernicus, see David C. Lindberg and Robert S. Westman, Reappraisals of the Scientific Revolution (Cambridge: Cambridge University Press, 1990).
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Galison, P. (2000). An Accident of History. In: Galison, P., Roland, A. (eds) Atmospheric Flight in the Twentieth Century. Archimedes, vol 3. Springer, Dordrecht. https://doi.org/10.1007/978-94-011-4379-0_1
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