oversight

Transportation Safety: Information Concerning Why a 1980 Aircraft Report Was Not Provided Earlier to the National Transportation Safety Board

Published by the Government Accountability Office on 1999-11-03.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

J=-y
  GAO
United States General Accounting Office                                 Office of Special Investigations
Washington, DC 20548



   B-283640


   November 3, 1999


   The Honorable Charles E. Grassley
   Chairman
   Subcommittee on Administrative Oversight and the Courts
   Committee on the Judiciary
   United States Senate

   Subject: Transportation Safety: Information Concerning Why a 1980 Aircraft Report Was Not
            Provided Earlier to the National Transportation Safety Board


   Dear Mr. Chairman:


   In connection with your ongoing concerns about the July 1996 TWA flight 800 crash of a Boeing
   747 aircraft, you asked us to determine why a Boeing report entitled Center Wing Fuel Tank
   HeatingStudy (also referred to as the PanamaStudy) dated March 14, 1980, was not provided to
   the National Transportation Safety Board (NTSB) until June 1999. To develop this information,
   we reviewed relevant documents and interviewed knowledgeable representatives of NTSB,
   Boeing Commercial Airplane Group, Boeing Military Group, and U.S. Air Force Oklahoma City
   Air Logistics Command (Air Force OC-ALC). We conducted our investigation from August 30,
   1999, to October 28, 1999, in Washington, DC; Seattle, Washington; and Oklahoma City,
   Oklahoma

   The following sections present the information we obtained on why the 1980 PanamaStudy was
   prepared; attempts by NTSB during the crash investigation to obtain relevant information that
   Boeing possessed; how and when the study finally surfaced; and views of Boeing, the Air Force
   and NTSB on the relevance of the study to the TWA flight 800 crash.

   1980 Panama Study

  Because the Air Force was experiencing problems with the center wing fuel tanks overheating in
  the Boeing E-4B aircraft, the military version of the Boeing 747, it contracted with Boeing to
  conduct a study to determine the cause of the problem and recommend solutions. Boeing's
  Military Group conducted the study and issued a report to the Air Force in 1980. The study
  concluded that under certain circumstances, the air conditioning wiring that ran through the fuel
  tank could create a potential safety problem. The PanamaStudy-named for the country in


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which it was conducted-did not recoummend changes to the E-4B aircraft; instead, it
recommended taking mitigating actions' to address the problem, such as flying the aircraft with
one of its tanks-the center wing fuel tank-empty.

Investigation of TWA Flight 800 Crash

NTSB, among other government entities, was involved in the investigation of the TWA flight 800
crash. As a party to the investigation, Boeing assigned technical experts on the design and
construction of the aircraft from its Commercial Airplane Group to work full-time with NTSB.

The NTSB Chairman and Director of Aviation Safety told us that as part of its investigation,
Boeing was requested to search its database for any information concerning heating problems
with the center wing fuel tanks. Both NTSB and Boeing officials told us that at that time the
Boeing Commercial Airplane Group told NTSB that Boeing had no data on tests conducted on
the heat buildup inside the center wing fuel tank of a 747 aircraft. Officials of Boeing's
Commercial Airplane Group admitted to us that the PanamaStudy should have been located and
turned over to NTSB in 1996, even though the Boeing Military Group prepared it for the Air
Force. They stated that human error caused an incomplete search to be made of the Boeing
records system for information'bn heat studies involving center wing fuel tanks.

NTSB's Chairman and Director of Aviation Safety also informed us that during the initial stage of
this TWA flight 800 investigation, Boeing officials told them that the temperature inside the
center wing fuel tank on the 747 was incapable of rising above a certain level. The Director said
that only after tests conducted by both Boeing and NTSB subsequent to the crash caused Boeing
to back away from its initial claim. As a result of its investigation of TWA flight 800, NTSB
issued safety recommendations to the F'ederal Aviation Administration (FAA) in December 1996.
These safety recommendations concerned potential heat buildup in center wing fuel tanks of
747s. Since the crash, FAA has issued a number of airworthiness directives and in October 1999
issued a Notice of Proposed Rule Making to implement additional safety recommendations
concerning center wing fuel tanks of 747s and other aircraft.

Surfacing of the 1980 Panama Study

A Boeing Military Group official told us that the PanamaStudy came to the group's attention in
December 1997 when a librarian in the Boeing Aerospace Operations Facility (part of the Boeing
Military Group) in Midwest City, Oklahoma, discovered the study during a "housecleaning"
effort. Because the Boeing Military Group determined that the report was the property of the Air
Force, Boeing turned the results over to Air Force OC-ALC.

In 1998, Air Force OC-ALC initiated an Independent Review Team (IRT) to discuss center wing
fuel tank issues connected with the E-4]B aircraft in light of the safety recommendations that
NTSB issued as a result of the TWA flight 800 investigation. In March 1999, Air Force OC-ALC
held an IRT meeting to continue to review safety issues concerning the center wing fuel tank of
the E-4B aircraft. As part of that meeting, the Air Force included the PanamaStudy on the
meeting agenda. Participants at this meeting included representatives from Boeing's
Commercial Airplane Group and Military Group and NTSB. Officials of both Boeing Commercial


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    Airplane Group and NTSB told us that this was the first time they had heard about the Panama
    Study. The NTSB Director told us that after this meeting, NTSB requested a copy of the entire
    study but instead received just a summary from the Air Force. In June 1999, after your
    Subcommittee's intervention, the Air Force provided the entire study to NTSB.

    Views Concerning the Relevance of the 1980 Panama Study

Air Force OC-ALC officials told us that when Boeing brought the PanamaStudy to their
attention, it was placed on the IRT meeting agenda for discussion. These officials told us that
they did not intentionally withhold the PanamaStudy from the NTSB, because both civilian and
military personnel within Air Force OC-ALC believed the PanamaStudy to be an operational or
readiness study, not a safety study. They added that they continue to believe that the Panama
Study was not relevant to the NTSB investigation.

We questioned Air Force OC-ALC officials about the apparent inconsistency in not believing the
study to be safety-related, even though it had been placed on the agenda of the IRT to be
considered in a review and validation of its current safety procedures. We were told by Air
Force officials that the PanamaStudy was placed on the agenda to show that the E-4B aircraft
was equipped somewhat differently and was capable of operating under more difficult
conditions than the commercial 747 version. They said that for this reason, the study was not
placed on the agenda for safety concerns.

Officials of both Boeing's Military and Commercial groups told us that to their knowledge, no
one intentionally withheld this study from NTSB. Like the Air Force, Boeing Military Group
officials characterized the PanamaStudy as an operational or readiness study, rather than a
safety study. Officials of Boeing's Commercial Airplane Group concluded that the PanamaStudy
was of limited use to NTSB's investigation of TWA flight 800 because although the E-4B and 747
aircraft are similar in design, the two aircraft have many internal differences. However, they
admitted that the PanamaStudy would have at least given NTSB some initial data concerning a
center wing fuel tank heating study of an aircraft that was the Boeing military version of the 747.

NTSB's Chairman and Director of Aviation Safety stated that had NTSB received the Panama
Study in 1996 following the crash of TWA flight 800, it would have saved valuable time and
resources in conducting its investigation. They added that this report would have been
particularly significant in that, at the start of the TWA flight 800 investigation, Boeing officials
initially told NTSB that the temperature inside the center wing fuel tank on the 747 aircraft was
incapable of rising above a certain level. As we noted earlier, the Director said that subsequent
tests conducted by both Boeing and NTSB did not support this claim.

The Chairman and Director also stated that the PanamaStudy might have been very helpful to
NTSB in its 1990 investigation of a Boeing 737 aircraft explosion at Manila Airport in the
Philippines. The explosion occurred in the aircraft's center fuel tank. According to both the
Chairman and Director, it is possible that if they had received this study in 1990, safety
recommendations made as a result of the TWA flight 800 investigation concerning fuel tanks
may have been issued sooner. The Director told us that safety recommendations issued by
NTSB routinely follow investigations of aviation accidents to prevent similar occurrences.


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We will make copies of this letter available to others on request. If you have any questions,
please contact me on (202) 512-7455 or Assistant Director Ron Malfi at (202) 512-6722. Senior
Special Agent Patrick F. Sullivan made a significant contribution to this report.

Sincerely yours,




Robert H. Hast
Acting Assistant Comptroller General
 for Special Investigations




(600585)




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