Transportation Safety:

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

OSI-00-2R: Published: Nov 3, 1999. Publicly Released: Nov 3, 1999.

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Pursuant to a congressional request, GAO provided information on the reasons why a Boeing report entitled Center Wing Fuel Tank Heating Study (also referred to as the Panama Study) dated March 14, 1980, was not provided to the National Transportation Safety Board (NTSB) to aid in its investigation of the 1996 Trans World Airlines (TWA) flight 800 crash until June 1999.

GAO noted that: (1) Air Force Oklahoma City, Air Logistics Command (OC-ALC) officials told GAO that when Boeing brought the Panama Study to their attention, it was placed on the Independent Review Team (IRT) meeting agenda for discussion; (2) these officials told GAO that they did not intentionally withhold the Panama Study from the NTSB, because both civilian and military personnel within Air Force OC-ALC believed the Panama Study to be an operational or readiness study, not a safety study; (3) they added that they continue to believe that the Panama Study was not relevant to the NTSB investigation; (4) GAO 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; (5) Air Force officials told GAO that the Panama Study 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; (6) they said that for this reason, the study was not placed on the agenda for safety concerns; (7) officials of Boeing's Commercial Airplane Group concluded that the Panama Study 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; (8) however, they admitted that the Panama Study 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; (9) 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; (10) 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; (11) the Director said that subsequent tests conducted by both Boeing and NTSB did not support this claim; and (12) 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.

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