Aircraft Accidents and Lessons Unlearned XXVIII: TWA Flight 6
On May 6, 1935, a Transcontinental and Western Air Incorporated Douglas DC-2 crashed near Atlanta, Macon County, Missouri. The Secretary of Commerce, as per section 2 (e) of the Air Commerce Act of 1926 dispatched two investigators to the site. All information for this accident was taken from the Air Commerce Bulletin Volume 7, Number 1, published in Washington, DC, July 15, 1935.
This accident investigation was accomplished in the days when accidents were common, not because of what was NOT available in technology but because the aviation community was learning how to convert a new industry into a civilian use. The United States’ entry into World War II was six years away and the fruits of the Chicago Convention of 1944 were exactly three years after that. Navigation equipment, autopilot, weather forecasting were decades in the future and even further along from perfecting.
After refueling at Albuquerque, New Mexico, the plane was cleared to fly to Kansas City, Missouri, despite the western night frequency of the aircraft’s two-way radio was non-functional. This prevented the flight crew from communicating with any ground stations for weather information or flight instructions.
When the flight reached Wichita, the ceiling dropped to 600 feet, a much lower ceiling than allowed for such a flight was authorized to fly, which was 700 feet. To be clear, weather forecasting in 1935 was antiquated by today’s standards; no Doppler radar, no satellite imaging and no 24-hour communications from other airports across the US. What exacerbated the situation was the airplane’s lack of air-to-ground radio communications, leaving the flight crew blind and deaf to any obstacles in the flight path. The air carrier’s ground station in Kansas City managed a one-way communication on the company frequency, directing the flight crew to attempt a landing at Kansas City despite the ceiling being so low.
Low on fuel, the pilots brought the aircraft below the clouds at Kirksville; for more than two miles, the aircraft flew low over slightly rolling terrain in scattered fog and mist. While navigating a low depression near the ground, the aircraft dipped its left wing to go around fog; the left wing dragged into the ground, throwing the aircraft out of control.
The investigation relied heavily on witness statements from those in Kirksville who saw the plane as it appeared and disappeared through the low clouds. Estimated altitudes, air speeds and engine noises proved to tell the final seconds of Flight 6. The days of cockpit voice recorders and flight data recorders were years away; minimum equipment lists were the result of accidents such as this.
Transcontinental and Western Air (TWA) flight 6 was unique for two reasons. First that the limited investigatory technologies available at the time did not hinder the investigators from completing a timely and efficient report; indeed, the report was completed in three months with valid recommendations The second reason was one of the accident victims, forty-six-year old Senator Bronson Cutting (R-NM), his death on this flight helped redirect a major change for the aviation industry.
The accident investigation was excellent in its simplicity. In the absence of any other fantastic outside contributors, e.g. ground witnessing of an engine fire; a barn or other farm structure in the airplane’s path or lightning strikes, the investigation focused squarely on the facts. Because the investigation did not veer into any bureaucratic nonsense or was belabored by ‘expert’ grandstanding, the recommendations were straight to the point; they hit the problems square on the head without any maybes or analytical side stepping. TWA flight 6 was a case study in root cause analysis in the days before root cause analysis.
Root cause analysis, used regularly by Federal Aviation Administration (FAA) inspectors, breaks down a problem to its lowest denominator, often by asking WHY, then subsequently asking WHY to every answer until the final answer cannot be broken down any further. This is evident in the findings where the cause was not the airplane dragging its wing into the ground but in that the airplane had been flown so close to the ground due to radio problems before dispatch (Recommendations b, c and d).
From this accident effective recommendations were written, including:
The installation of instrument approach facilities at airports;
Licensing of airline dispatchers;
Improved fuel reserve regulations;
Rules dictating pilot flight-time limitations.
These recommendations were proactive; more importantly, they stayed on topic, which was aviation safety. The same cannot be said today about recommendations today that tend to go off topic and wander into agenda items. Furthermore, today the focus is on ‘probable’ cause, not root cause; this is the equivalent of a ‘maybe’ cause, what might have happened, not necessarily what did happen.
It is also indicative of how accident investigation has become overly complicated. This accident took less than three months from the tragedy to the publishing of the recommendations and findings. The average National Transportation Safety Board (NTSB) aviation investigation takes over a year; months pass before an initial update is even released. For instance, Atlas 3591 occurred over five months before this article and no update; this is unbelievable.
The NTSB uses every available technology and dozens of investigators (TWA flight 6 – two investigators), yet in the time between an accident and the first update, a reoccurrence of the same circumstances that caused a first crash can be duplicated.
The second consequence of the TWA flight 6 accident was the death of Senator Bronson Cutting (R-NM). The death of a member of Congress was not remarkable except for the Senator’s loss became the catalyst to move towards separating Commerce from Transportation. The Civil Aeronautics Authority Act of 1938 was adopted in the aftermath of Senator Cutting’s passing. This Act formed the Civil Aeronautics Board, the predecessor of today’s FAA.
The transfer of aeronautics from Commerce to Transportation took responsibility for aviation out of the commerce field; aviation agencies had moved from the oversight of business (under Commerce) to the oversight of safety. With the admission of the US into World War II, other changes would occur, including the introduction of the International Civil Aviation Organization (ICAO), which launched the US and its allies into the international air market in 1945.
TWA flight 6 was a standout accident investigation, especially for its time. Qualified investigators were focused, their attention on safety and what needed to change. Findings and Recommendations were clear; their purpose was to improve aviation, not mire it in ambiguities. The fledgling industry embraced new technologies, modifying their techniques to adopt the new technologies and foster innovation. Most importantly, there was no arrogance, no pride. Aviators knew their limitations and those investigating accidents knew theirs. And because of this, the aviation industry grew to what it is today.
Will it stay safe?