The companion piece “The bulletins” gives the documents of 1972 and 1973. This one gives what replaced them after Ermenonville: the directive itself as the Federal Register printed it on 2 April 1974, the Administrator’s account of why, and the recommendations that followed in Washington and Paris. The directive’s text is from the Register and from its 1975 revision; Butterfield’s and Basnight’s words are as the Washington Post reported them, in the articles that the Senate printed in the Congressional Record on 28 March 1974; the Commission’s recommendations are from its report.
7 and 22 March 1974: the telegrams
The directive that had been drafted in June 1972 was adopted on Thursday 7 March 1974, four days after Ermenonville, and sent to every United States operator of the DC-10 by individual telegram, effective at once. Its preamble, as the Federal Register printed it: “Pursuant to the authority of the Federal Aviation Act, delegated by the Administrator, an airworthiness directive (AD) was adopted on March 7, 1974, and made effective immediately as to all known United States operators of McDonnell-Douglas DC-10 series airplanes, because of an apparent in-flight depressurization which may have been associated with an improperly secured cargo door. The telegraphic AD of March 7, 1974, required certain modifications of airplanes not already incorporating them, prior to further flight. In addition, that telegraphic AD requires that certain checks for proper security of the cargo doors be accomplished by a flight crewmember prior to each flight (paragraph 2.), and requires immediate depressurization of the airplane and landing at the nearest suitable airport, upon the observation of any abnormalities in pressurization in flight (paragraph 3.).”
A second telegram on 22 March amended it, “since the FAA determined that further corrective action was required.” Notice and public procedure were dispensed with because “immediate corrective action was required,” and the directive was printed in the Register “to make it effective as to all persons,” under the signature of James F. Rudolph, Director of the Flight Standards Service, on 28 March. Its number was Amendment 39-1811, Docket 13593.
The text
Its text, in the form the Register gave it, begins: “To prevent possible in-flight depressurization of the airplane that might result from the opening of an improperly secured cargo door, accomplish the following: 1. Prior to further flight, unless already accomplished, perform the modifications and functional checks referenced below as follows: (A) Install inspection ports and placards in all cargo doors and perform functional check of door systems and operation in accordance with McDonnell-Douglas Alert Service Bulletin A52-35 dated June 19, 1972, or later FAA-approved revisions. (B) Modify all cargo door latch actuator wiring in accordance with McDonnell-Douglas Service Bulletin 52-27 dated May 30, 1972 or later FAA-approved revisions. (C) Except for those aircraft which have been modified in accordance with McDonnell-Douglas Service Bulletin 52-49 dated October 25, 1973, or later FAA-approved revisions, replace the strike plate and adjust the switches on all forward, center, and aft cargo doors and install a support and plate on the aft cargo door in accordance with McDonnell-Douglas Service Bulletin 52-37.” The three bulletins of June and July 1972, twenty months later, with the force of law in front of them.
Paragraph 2 required a flight crew member, before each flight, to check each cargo door that had been opened since the last check: that the restraint curtain was in place, that no foreign matter was in the locking mechanism, that the mechanism was in its proper position, and, “(4) Ensure proper locking pin placement by visual check through inspection ports”; doors known not to have been opened were to be checked from outside, and all cargo door warning lights were to be out before taxi. Paragraph 3 required a descent and landing at the nearest suitable airport if any abnormality in pressurisation was seen in its initial phases. Paragraph 4: the checks were to be done by a flight crew member “notwithstanding any other requirements of the Federal Aviation Regulations.” Paragraph 6 required the warning-system wiring of bulletins 52-43 and 52-44 within thirty days; paragraph 7, “On or before July 1, 1974, accomplish the cargo door latching mechanism and warning system rework in accordance with McDonnell-Douglas Service Bulletin 52-49, Revision 1, dated March 15, 1974”; paragraph 8, the limit switch covers of 52-54 by the same date. A note recorded that the FAA’s carrier inspectors would at the same time amend the airlines’ training programmes so that flight crews were “thoroughly familiar with, and indoctrinated in, the operation of locking cargo doors,” including “method of visual check to ensure engagement of locking pins through exterior inspection ports.”
The directive was revised four times more by December 1975, when it stood as AD 74-08-04, applying to every DC-10, and still began with the same sentence about an improperly secured cargo door.
The Administrator’s explanation
Butterfield’s letter to Reed explained the change of instrument. Soon after the Paris crash, he wrote, “I learned that certain of these modifications had not been carried out, and that there were some uncertainties in the records available to us with regard to the status of DC-10 aircraft.” He then “directed that the door modification program be formalized through ADs and made the subject of an immediate FAA regulatory surveillance program. An AD was issued that day. It meant, of course, that no DC-10 could be flown by a U.S. operator except in compliance with its terms.” The directive was also sent to every foreign airline flying the type, “which was not necessarily the case with the original service bulletins,” the Post noted, and was not binding on them.
Basnight told the Post that the inspection of all 134 DC-10s after the crash found two without the bulletins’ modifications, both foreign, one of them the Turkish aircraft, “which was purchased after the bulletins had been issued.” The other had since been modified. “The attitude of McDonnell-Douglas has changed with the demonstration of the two accidents now,” he said. “The company has adopted the position that whatever is required, they’ll do it.”
The Board again
The Safety Board, which had no accident of its own to investigate in France, issued three further recommendations to the FAA in 1974: A-74-27, that the provisions of Service Bulletin 52-49, the closed loop, be made mandatory by an immediate directive; A-74-28, that the FAA “expedite your resolution of the cabin flooring venting problem so that the flooring modification can be required by airworthiness directive at the earliest practical date”; and A-74-29, that the directive of March be amended “to require an improved viewing window and illumination of the lock pin area,” so that the pins could actually be seen.
The second was answered in 1975 by AD 75-15-05, the “floors and doors” directive, which required the floors of the DC-10, the TriStar, the 747 and the A300 to be made able to withstand a sudden opening in the fuselage without collapsing, and later by Amendment 25-54 to the certification rules, which wrote a twenty-square-foot hole into the design requirement for every pressurised transport, together with a window, a warning and an interlock for every outward-opening door. The FAA’s own account of these rules, written for its engineers, says that the agency “did not take any action to review the design of the cargo door systems on other transport airplanes” until a 747’s cargo door opened off Honolulu in February 1989 and nine passengers were lost; the review that followed produced numerous further directives.
The Commission
The French Commission’s recommendations, signed in Paris, began by quoting the Board’s two of 1972 and observed that the Ermenonville accident “has shown that the modifications made to the locking system, modifications moreover incompletely applied to TC-JAV, were inadequate and that the measures proposed to mitigate sudden decompression had not been carried out.” It recommended that the new procedures and modifications decided since the accident “should be mandatory,” attention to cargo door closing, locking and checking systems “in the case of all the aircraft,” a review of the routing of flight controls where structural damage could cut all of them at once, and training of the people who close cargo doors “in accordance with a detailed programme established by agreement between the manufacturer and the airline and approved by the official services.” Its fourth recommendation was the one about paper.
“Examination of the procedures used after the Windsor (Ontario) accident, in order to advise the manufacturer and the airline of the necessary modifications, has shown that the method of the ‘airworthiness directive’ was not used; for that reason, the recommended measures were not mandatory and appropriate means were not employed to bring the matter to the attention of those concerned. The Commission recommends that the mandatory procedure of ‘airworthiness directives’, whatever the financial repercussions, should be selected whenever safety could be at serious risk.”
The phrase “whatever the financial repercussions” is the Commission’s. Nowhere in the documents above does anyone say what the financial repercussions of a directive in June 1972 would have been, or to whom. The FAA’s retrospective for its engineers says that the manufacturer “proposed to the FAA that rather than issue an AD, the FAA allow the manufacturer to issue the service bulletin as mandatory (an unprecedented action for an urgent safety issue of this magnitude),” and that the FAA concurred. The same page adds the caveat the entry keeps: because the records of the accident aircraft “improperly indicated that corrective service bulletins had been incorporated, it is unclear whether issuance of an airworthiness directive would have been effective in avoiding this accident.” The Commission, which had the records in front of it, chose the word “mandatory” anyway, and gave its reason in the clause before: that under a bulletin, “appropriate means were not employed to bring the matter to the attention of those concerned.” A handler at Orly who had seen the window and did not know what it was for was one of those concerned.