TABLE OF CONTENTS
 
 

  I. Executive Summary..........................................................page 1

  II. How the Review Was Conducted....................................page 4

  III. The Government's Investigation of Flight 800..............page 5

  IV. The Missile Theory.........................................................page 7

  V. The Explosion of the Center Wing Fuel Tank.................page 12

  VI. The Break-up Scenario...................................................page 14

  VII. Investigating Major Air Disasters.................................page 15

  VIII. Recommendations.........................................................page 18

  Appendix................................................................................page 19
 
 

I.  EXECUTIVE SUMMARY

 On the night of July 17, 1996 TWA Flight 800 crashed into the Atlantic Ocean off the coast of Long Island, New York.  All 230 people on board were killed.  The federal government's investigation into this tragedy has been unprecedented.  Almost two years after the crash, many people still have questions about what caused this tragedy.  This report attempts to answer those questions by reviewing the federal government's investigation into Flight 800.

 Why did I undertake this investigation?

 In July of 1997, near the one-year anniversary of the crash, the Transportation and Infrastructure Subcommittee on Aviation held a hearing on Flight 800.  During my research of this tragedy prior to the hearing, I came across a number of newspaper, magazine and Internet articles critical of the government's investigation.  The main criticism (criticism that persists to this day) is that the NTSB and FBI were not paying enough attention to the missile theory, and that key eyewitness testimony was being ignored.  At that hearing I asked a number of questions of the NTSB and FBI about these and other issues.  Two weeks after the hearing I sent follow-up questions to the NTSB and FBI regarding their investigation.  I also continued to closely monitor and review all aspects of the tragedy.  I did so, initially, in response to the many reports that key evidence was being ignored or misinterpreted.  I kept Aviation Subcommittee Chairman John J. Duncan, Jr. and the ranking Democrat on the subcommittee, Congressman William Lipinski, informed of my correspondence with federal investigators, and my concerns about the many reports of problems with the investigation.

 In September of 1997 I was asked by Chairman Duncan to investigate all of the circumstances surrounding the crash of TWA Flight 800 and prepare a report for the subcommittee.  This report is the result of my ten-month review.  To my knowledge, no other committees in the Congress have undertaken a close examination of the federal government's investigation of TWA Flight 800.  Given the magnitude of this investigation, I have been somewhat disappointed that the major oversight committees in the Congress have not taken a more active interest in the Flight 800 investigation.

 While my investigation uncovered some problems and anomalies with the federal government's investigation, the NTSB and the FBI did a remarkable job in examining this tragedy.  The hundreds of men and women who sacrificed so much of their time and their emotional strength examining this tragedy should have our lasting gratitude.  On the whole, the Flight 800 investigation was carried out in a highly professional, careful and thorough manner.

 I found no conclusive evidence to counter the NTSB's assertion that the break-up of the airplane was initiated through a fuel air explosion in the center wing fuel tank.  I also did not uncover any conclusive evidence contradicting the NTSB and FBI's assertion that there is no evidence that the crash was caused by a bomb or a missile.  While a few eyewitness accounts are not consistent with the break-up scenario posited by the NTSB and FBI, the bulk of the eyewitness statements are consistent with the break-up scenario.

 I am greatly disturbed by the vast number of conspiracy theories that continue to proliferate on the Internet and other media.  I closely examined a number of these theories and scenarios, including friendly fire from the U.S. military, a terrorist missile, electro- magnetic interference, a meteor and a bomb.  These theories are not supported by the evidence.  It is important to note that the NTSB and the FBI also closely examined these theories.  In fact, the U.S. military's top missile experts examined every piece of recovered wreckage over a period of several months.  Not a single piece of evidence was uncovered which indicated that a missile or a missile fragment brought down Flight 800.

 While it remains true that investigators have yet to uncover evidence of an ignition source inside the CWF tank, all of the other evidence recovered indicates that there was an explosion of fuel vapors inside the tank, and that this was the initiating event that caused the break-up of Flight 800.  I think it is also important to note that Boeing, the plane's manufacturer and a key party to the investigation, is in general agreement with the NTSB's break-up scenario.

 It should also be noted that, up until the Flight 800 crash, there has never been an in-flight fuel tank explosion involving Jet A  fuel (the kind of fuel used on Flight 800) caused by an internal ignition source.  However, in May of 1990 a Philippine Airlines Boeing 737-300 exploded and burned while being pushed back from the gate at Manila Airport.  The source of the explosion was the center fuel tank, and the investigation determined that the likely ignition source came from inside the tank.  In addition, there have been several accidents involving the fuel tanks of military aircraft.  While none of the military accidents involved Jet A fuel, they did reveal the difficulty of eliminating internal ignition sources inside aircraft fuel tanks.

 If, for argument's sake, the government is covering-up the real cause of this tragedy, it is a cover-up involving hundreds, if not thousands of individuals.  I find it highly unlikely that a cover-up of this magnitude could succeed -- especially in today's media environment.  In addition, the crash of TWA Flight 800 has been scrutinized and reviewed by hundreds of journalists in this country and overseas.  Not one has uncovered a single piece of solid evidence or testimony from a participant in the investigation that points to a cover-up or any nefarious activity on the part of our government.  My staff personally interviewed many of the individuals directly responsible for this investigation.  My staff received the full cooperation of the NTSB throughout my review.  At no point did I or my staff get any indication that the NTSB was attempting to hide or cover-up anything.

 I did find, however, that there was tension between the FBI and NTSB during the initial months of the investigation.  This tension was, to a certain extent, to be expected when two agencies are investigating a crash of this magnitude from two different perspectives.  In the end, however, this tension did not, in my opinion, compromise the investigation in any serious way, although it may have given rise to some of the many rumors and conspiracy theories surrounding Flight 800.  The government's investigation of Flight 800 also revealed some flaws in the manner in which the NTSB investigates major airline accidents.  This report includes recommendations on how to address these problems.

 While the FBI was responsive to my initial inquiries, I have been disappointed that they have yet to respond to an April 2, 1998 letter I sent to the FBI's New York office asking several questions related to the FBI's identification of vessels and aircraft in the proximity of Flight 800.  The FBI's complete response to these questions will go a long way in addressing some of the many questions that have been raised about the government's Flight 800 investigation.  I am also dismayed that the FBI has refused to release to the public the eyewitness statements and certain laboratory test results related to the Flight 800 investigation.  I found the FBI's arguments that releasing this evidence could compromise a future criminal prosecution to be specious and unwarranted. Again, making public this evidence will go a long way in addressing some of the lingering doubts and questions surrounding the Flight 800 tragedy.  I believe our subcommittee should urge the FBI to release this evidence as soon as possible.

 Included in my report is an appendix comprising copies of the correspondence I engaged in with the NTSB, FBI, Central Intelligence Agency and the White House.  This correspondence will provide the subcommittee with some valuable insights into the government's investigation, and answer a number of questions related to how the investigation came to certain conclusions.

 A hearing by the Aviation Subcommittee should be held to review all of the issues related to the government's investigation of Flight 800.  Such a hearing would help to further dispel the rumors and untruths that continue to surround this tragedy.  It would also give the subcommittee an opportunity to hear from the Federal Aviation Administration, NTSB, FBI and the airline industry on how best to respond to what we have learned from the Flight 800 investigation.

II.  HOW THE REVIEW WAS CONDUCTED

 This report is the result of a ten-month review conducted by me and a member of my staff.   Representatives from the major parties to the investigation were interviewed, including representatives from the NTSB, FBI, Boeing, Airline Pilots Association and TWA.   Other participants and certain eyewitnesses were also interviewed, including the Suffolk County (NY) Medical Examiner, and members of the 106th Air Rescue Wing of the New York National Guard.  The hangar in Calverton, New York that houses the wreckage of Flight 800 was visited and reviewed by a member of my staff.  The lead missile expert from the Navy, Dr. Richard Bott, was interviewed on several occasions by a member of my staff.  Other outside experts on such things as surface-to-air missiles, capabilities of known terrorist groups, Navy operations, meteors, wreckage recovery, aerodynamics, eyewitness testimony and meteors were also consulted.  Finally, I met with former Congressman Norman Mineta, chair of the National Civil Aviation Review Commission, to discuss the commission's findings on aviation disaster investigations.

 In addition, I sent questions to the NTSB, FBI, CIA and the White House on various issues related to the Flight 800 probe.  The main thrust of my review was on the investigatory work of the NTSB.  Throughout my review the NTSB has been extremely cooperative, forthcoming and accommodating.   While the FBI took several months to respond to my first letter of inquiry, their initial responses were thorough and professional. However, as of this writing, the FBI has yet to respond to a letter I sent to Assistant FBI Director Lewis D. Schiliro on April 2, 1998.  The correspondence between my office and the above named agencies is included in the appendix.

 In addition to first-person interviews with key participants and outside experts, and direct correspondence with the investigating agencies, I also conducted independent research on a number of issues related to Flight 800.  This research covered areas such as the capabilities and operational functioning of various surface-to-air missiles known to be in the arsenals of certain countries hostile to the U.S. (e.g. Iran, Iraq, North Korea), public statements of officials from countries or terrorist groups hostile to the U.S. in the months leading up to the Flight 800 crash, properties of certain types of jet fuel, previous airplane accidents involving fuel tank explosions, and meteor showers.

 This report is the result of the interviews, correspondence and independent research my staff and I conducted.
 
 
 

III.  THE GOVERNMENT'S INVESTIGATION OF FLIGHT 800

 On July 17, 1996, at about 8:31 p.m., TWA Flight 800, N93119, a Boeing 747-100, crashed into the Atlantic Ocean off the southern coast of Long Island, New York.  The airplane crashed shortly after takeoff from Kennedy International Airport in New York City.  The airplane was on a regularly scheduled flight to Paris, France.  The airplane was destroyed and 230 people were killed.

 Immediately following the crash thousands of local, state and federal government personnel responded to the tragedy.  According to the FBI, within 24 hours of the crash, approximately 400 FBI and other state and local enforcement agents were working full-time on Long Island investigating the incident.

 The federal government's investigation into the crash of Flight 800 was unprecedented in U.S. history.  The two main federal entities involved in the investigation, the Federal Bureau of Investigation and the National Transportation Safety Board, worked tirelessly to determine what caused this tragedy.  More than 95 percent of the airplane was recovered.  A large portion of the airplane was reconstructed.  Every scrap of wreckage was carefully analyzed.  Thousands of pieces of wreckage were tested and retested.  Experts on ballistic missiles, meteors, bombs and airplane disasters sifted through the wreckage for months on end.  CIA experts on surface-to-air missiles closely reviewed eyewitness statements to determine whether any of the eyewitness descriptions matched known missile launch characteristics.  Two separate animations of the accident were made, one by the CIA and one by the NTSB.

 The NTSB and FBI conducted numerous tests involving different types of bombs, missile warheads and other explosive devices.  As noted above, the FBI worked closely with missile experts from the U.S. military.  Metallurgists were called in to examine the hundreds of holes found in pieces of the wreckage.  These experts examined thousands of pieces of wreckage.  None of these experts found any evidence that a missile or a missile fragment hit Flight 800.  In addition, no evidence of a bomb explosion was found.  The FBI also analyzed hundreds of pieces of suspicious material found in the bodies of the victims.  All of the material recovered from the victims' bodies came from the aircraft.  None of the autopsy evidence indicated that a bomb or missile was involved in the tragedy.
 
 The FBI also questioned officials from the U.S. Navy regarding the possibility that Flight 800 was downed by friendly fire from the U.S. military.  According to the FBI, no evidence was found indicating that the U.S. military was in any way involved in the crash of Flight 800.

 In November of 1997, the FBI announced that it was ending its active investigation of Flight 800 because it had not found any evidence of a criminal act.  The FBI did note, however, that it was withholding from public disclosure all eyewitness statements and other raw investigative details until the NTSB made a definitive declaration that the crash was indeed accidental.

 In December of 1997, the NTSB held a week of public hearings in Baltimore, Maryland.  At that hearing the NTSB presented a wealth of data, information and testimony.  The hearing did not uncover any "smoking gun" revealing what caused Flight 800's CWF tank to explode.  However, it did, in excruciating detail, reinforce the NTSB and the FBI's earlier findings that the initiating cause of the crash was the explosion of fuel vapors in the CWF tank.  It presented voluminous information on potential ignition sources.  In addition, the hearing attempted to explain to the public why investigators have all but ruled out the possibility that the crash was caused by a bomb, missile or meteor.

 In the seven months following the Baltimore hearing, the NTSB has conducted additional tests on Jet A fuel, and, working with Boeing, closely examined the wiring on 747s and other commercial aircraft.  The NTSB has also further examined the miles of wiring recovered from the Flight 800 wreckage.  While the NTSB has yet to find any evidence of an ignition source inside the CWF tank, the evidence analyzed to date still points to a CWF tank explosion as the initiating event of the airplane's break-up.  Boeing's engineers concur with the NTSB's conclusions about the break-up sequence.

 In response to safety recommendations made by the NTSB in December of 1996 and April of 1998, the FAA and Boeing are working on new guidelines on how to inspect 747 fuel quantity indicating systems.  In addition, Boeing conducted a review of fuel tank wiring on all of its 747s.  Boeing also has been actively working on a series of fuel system related service bulletins  that the company feels will address the NTSB recommendations.  The FAA is also examining recommendations made by the NTSB that thousands of 747s and other commercial airliners be rewired to reduce the risk of a fuel tank explosion.
 
 Investigators have, for the most part, completed their review of the wreckage at Calverton.  However, the NTSB continues to conduct tests and other reviews to learn more about how the crash may have occurred, and to search for other potential ignition sources.  The NTSB, which has spent more than $31.4 million on the Flight 800 investigation, has yet to issue a probable cause determination.
 

IV.  THE MISSILE THEORY

 Within hours of the crash of Flight 800, CNN and other news outlets were reporting that eyewitnesses saw something streaking upward in the sky.  It has been these reports that have resulted in rumors, articles, at least one book and numerous web sites on the Internet all purporting that Flight 800 was downed by a missile.  It was these persistent reports that first led me to more fully examine this tragedy.

 The FBI interviewed more than 400 individuals who reported seeing something in the sky south of Long Island the night of July 17, 1996.  According to the FBI, 115 of these individuals reported seeing something ascend into the sky.  Of these, only three reported seeing something ascend toward a second object.  In addition, the FBI and its law enforcement team conducted some 860 interviews within one month of the crash.  More than 7,000 law enforcement interviews have been conducted in connection with the Flight 800 investigation.  The NTSB was initially barred by the FBI from participating in most of these interviews.  However, according to the FBI, all interview/witness statements have been shared with the NTSB.  In addition, the FBI and NTSB created a Witness Group Panel.  In hindsight, it may have been prudent for NTSB staff to accompany the FBI on the eyewitness interviews.  However, the fact that this was not done did not, in any substantive manner, compromise the investigation.  The NTSB now has the FBI eyewitness statement summaries, and is committed to reconvening the NTSB witness group which includes representatives from all of the parties to the investigation.  As noted earlier, the FBI also fully investigated the possibility that a missile fired by the U.S. military was responsible for downing Flight 800.

 Was a missile fired at Flight 800?

 Based on all the evidence my staff and I have reviewed, including summaries of the eyewitness interviews conducted by the FBI, it is my conclusion that the majority of the eyewitness testimony is consistent with the break-up scenario postulated by the NTSB.  In all likelihood, what the eyewitnesses saw was Flight 800 in various stages of crippled flight.  Some of the eyewitnesses my staff member interviewed gave testimony that is entirely consistent with the NTSB's scenario.  Although we did not interview a single witness whose testimony was inconsistent with the NTSB's scenario, there are a small number of eyewitnesses who are adamant that they saw a streak of light ascending from the horizon and that the streak of light preceded an explosion.  I have no doubt that these eyewitnesses saw what they say they saw.  However, it should be pointed out that all of the eyewitnesses were at least eight to ten miles from Flight 800.  Visibility was limited that night.  According to the NTSB,

"Most of the eye witnesses were 10 miles or more from the accident site and at such a distance, it would have been very difficult to see even a Boeing 747.  Further, it would have been extremely unlikely that at such distances eye witnesses could have seen a much small target, such as a missile, even under the best of conditions.  Even those witnesses who were closest to the scene (more than eight miles away) would not likely have been able to see a small object such as a missile.  However, some witnesses could have, and apparently did see, evidence of light or a fireball...Navy experts have indicated to us that it is unlikely that a shoulder launched anti-aircraft missile would have been visible from 10 miles away given the visibility conditions that prevailed on the night of the accident and the position of the witnesses."

 While NTSB staff did not accompany the FBI during the eyewitness interviews, missile experts from the Army's Missile and Space Intelligence Center did accompany FBI agents during some of the interviews early in the investigation.  In addition, the FBI asked the CIA to assist in analyzing the eyewitness testimony.  The CIA, working with missile experts in the U.S. military, conducted a detailed analysis which focused on determining whether the eyewitnesses saw a missile.  According to CIA Director Tenet, "Each of the CIA analysts involved in the Flight 800 investigation had considerable experience analyzing foreign surface-to-air missiles; the lead analyst was for eight years chief of the CIA branch responsible for analyzing all foreign surface-to-air missile developments.  Further, many of their managers, who were continuously involved in monitoring the analysts' progress, had decades of technical weapons analysis experience."  It should be noted that CIA analysts did not personally interview any of the eyewitnesses.  They analyzed the statements only.
The CIA concluded that what the eyewitnesses saw was Flight 800 in various stages of crippled flight – not a missile.
 
 The one criticism I have of the CIA is that in October of 1997 the CIA, without the knowledge of the FBI, publically announced its conclusions that Flight 800 was not downed by a missile.  Given the fact that at the time of its announcement the FBI and the NTSB had not completed their investigations, the CIA announcement was ill-advised, premature and unwarranted.  Rather than dispel the many rumors and conspiracy theories surrounding Flight 800, the CIA pronouncement actually added fuel to the fire being generated by the growing number of conspiracy theorists.

 The CIA pronouncement, while ill-advised and poor policy, was not part of any nefarious government cover-up.   The CIA analysis of the eyewitness testimony is one of a number of examples of how seriously the FBI and NTSB took the eyewitness testimony and the missile theory.

 The NTSB also consulted with an eyewitness testimony expert to get a better idea of how accurate and reliable eyewitness testimony is – especially eyewitnesses to a disaster of this magnitude.   The expert found nothing surprising in the eyewitness statements.  The fact that several eyewitnesses saw something that is counter to what other eyewitnesses related, and counter to what the NTSB postulates happened to Flight 800, is not unusual.  There are numerous scientific studies which detail how the accounts of eyewitnesses to the identical event can give wildly variant testimony.  The NTSB had wanted to have experts on the limitations of eyewitness observations testify at the NTSB's public hearing last December.  These witnesses were not called at the express request of the FBI's lead investigator, James Kallstrom.

 In summary, the majority of the eyewitness statements are consistent with the NTSB's break-up scenario.  The majority of the eyewitness statements do not describe a missile launch.  The fact that there are a small number of eyewitnesses whose testimony is not consistent with the NTSB's scenario is, according to eyewitness and other experts, not unusual.

 The statements of the eyewitnesses are important evidence.  The FBI and NTSB exhaustively reviewed the eyewitness statements.  But the most important evidence is the wreckage itself.  As noted earlier, 95 percent of the airplane was recovered.  Every piece of the wreckage has been closely analyzed and reviewed by a wide range of experts – including missile experts from the U.S. military.  None of these experts found any evidence that Flight 800 was hit by a missile, missile fragment, meteor or other foreign object.  In addition, there is no evidence that the initiating event was an explosion or shock wave outside the airplane.

 According to a report compiled by one of the military experts who reviewed the wreckage, "...it is inconceivable that a warhead could have detonated in or near the fuselage without leaving evidence of high-velocity fragmentation damage somewhere on the recovered wreckage."  No such damage was found on any of the wreckage.  In fact, the only evidence of any type of explosion found on the wreckage was found in the area of the CWF tank.  The evidence indicates that the explosion came from the inside of the tank.  The report further noted that,

"Some unexplained damage characteristics on these structures [the wings] have puzzled investigators, for example, the severe shattering of the left wing upper skin.  While the damage mechanisms involved may not be completely understood, the recovery and reconstruction of TWA Flight 800 is the most comprehensive undertaking of its type ever made.  This wing damage may be typical for severe water impacts but has gone unnoticed in previous mishaps due to the lack of recovery and reconstruction of debris.  Further, the left and right wings of Flight 800 impacted the water in different attitudes, as evidenced by the damage to the engines, which may explain the disparity in damage between the two structures.  These damage characteristics are not deemed characteristic of a missile impact, but without validating test data this conclusion cannot be made with 100% certainty."

 The experts at China Lake examined a number of possible missile scenarios, including a missile passing through the aircraft and not exploding, and the possibility of a missile warhead fragment hitting the aircraft and causing the explosion of the CWF tank.  Again, the experts found no evidence indicating that Flight 800 was hit by a missile or a missile warhead fragment.  In discussing the possibility that Flight 800 could have been struck by a small missile warhead fragment, the China Lake report noted that,

"Although the possibility of this scenario exists, the probability is extremely low.  For a missile shooter to launch the weapon, the weapon to fly at the target, the target to be just beyond the kinematic envelope of the weapon, the warhead to be properly positioned at self-destruct, and one of the very few fragments to impact in an area to penetrate the thick wing skin with enough residual energy to initiate an explosion is stretching credulity to the point that this scenario must be considered a low-priority area of concern."

 It has also been alleged that radar data indicates that Flight 800 was hit by a missile.  The FBI, NTSB and other experts closely examined the radar data.  According to the NTSB, "...there are no primary radar returns that appear close in distance and time to TWA 800 that are not attributed to known airplanes or to surface vehicles."

 A thorough, careful and expert analysis of the eyewitness testimony, radar data and wreckage was conducted to determine if a missile was responsible for the Flight 800 tragedy.  To date, not one piece of concrete evidence has been uncovered indicating a missile was responsible for this tragedy.  My investigation has confirmed the findings of the NTSB, FBI and CIA.   Several private citizens have expended an enormous amount of time  investigating the Flight 800 tragedy in an attempt to prove that a missile was responsible.  I or my staff have spoken to and met with some of these people.  We listened to what they had to say.  We reviewed their evidence.  Despite the good intentions of many of these individuals, their assertions are based more on second and third-hand statements than the actual evidence.  If one were to believe any of these theories, one would have to believe that the federal government is involved in a massive cover-up involving hundreds, if not thousands, of individuals.  As noted earlier in this report, I do not believe such a scenario is credible.  Giving any type of credence to such unsubstantiated theories does an injustice to the hundreds of dedicated government employees who worked so hard and so long to solve the Flight 800 mystery.  In closing this section, I'd like to quote from missile expert Richard Bott's report:

"During this author's impartial involvement in the investigation, there was never a doubt that every agency involved was focused on one specific goal – identifying the cause of the accident.  The public should feel confident and take pride in the fact that all available resources were devoted to this goal without regard to political implications or cost.  The criminal investigation by the FBI was tenacious in tracking down every single possible lead; the NTSB examined every aspect of the incident, often in microscopic detail, searching for all clues; all other agencies involved performed similarly, bringing professionals together from around the world.  The open flow of information between these agencies was effective in allowing investigators to analyze every aspect of the mishap.  The author was granted complete access to data compiled by the FBI and NTSB, which greatly facilitated the analysis detailed in this report...Any rumors of conspiracy or cover-up are, this author's experience, completely and absolutely unfounded."
 
 
 
 

V.  THE EXPLOSION OF THE CENTER WING FUEL TANK

 After almost 24 months of exhaustive analysis and investigation of the wreckage, radar tapes, eyewitness testimony and other evidence, the NTSB is maintaining that the initiating event for the break-up of Flight 800 was a fuel air explosion in the center wing fuel tank.
 
 Prior to its takeoff on July 17, 1996, Flight 800 was delayed on the ground at Kennedy Airport.  For two hours prior to takeoff the air conditioning packs on Flight 800 were running.  On a 747 the packs are located underneath the CWF tank.  Ground crews did not fill the CWF tank, as is normal practice on a New York to Paris flight.  However, there was residual Jet A fuel on the bottom of the CWF tank, which is about the size of a two-car garage.  According to the NTSB, its tests indicated that "the temperatures in the center fuel tank were higher than previously believed, and they were well within the lower and upper flammability limits for Jet A fuel under conditions simulating the TWA Flight 800 flight...it would have been possible to ignite the fuel (Jet A) with relatively little energy."

 It should be noted that Boeing engineers all of its aircraft to eliminate the possibility of any ignition source inside the fuel tanks.  One of the scenarios being postulated by the NTSB is that frayed wiring near the CWF tank caused a high voltage wire to arc over to a low voltage wire connected to one of the CWF tank fuel probes.  This arcing caused a spark inside the CWF tank which in turn ignited the fuel vapors.  To date, the NTSB has been unable to find any evidence of arcing or sparks from any of the wires leading into the CWF tank.  Nor has the NTSB been able to uncover any evidence of what ignited the fuel vapors in the CWF tank.  But, based on NTSB sanctioned tests and safety reviews conducted by Boeing, the NTSB believes that wiring could pose a safety hazard.

 In response to these concerns, in September of 1997 Boeing officially formed its Fuel Systems Safety Program, which is charged with thoroughly reviewing the safety of existing fuel systems and examining means of further advancing the safety of those systems.  Boeing continues to work with the FAA to further enhance the safety of airplane fuel systems, including fuel system wiring.

 In December of 1996, based on its preliminary findings in the Flight 800 investigation, the NTSB made recommendations to the Federal Aviation Administration for changes in Federal Aviation Regulations (FARs) to preclude explosive fuel-air mixtures in fuel tanks of commercial transport airplanes.  The NTSB recommended that the FAA consider measures such as nitrogen inerting of fuel tanks, insulating the fuel tanks, fuel cooling and filling the CWF tank.

 In response to the FAA's request for comments on the NTSB recommendations, the airplane manufacturers and airline operators prepared a joint response on August 1, 1997.  They concluded that the NTSB recommendations "...will not significantly improve safety.  Engineering studies showed that some of these recommendations, such as fuel cooling, provided only a small reduction in the average fleet exposure to flammable fuel-air mixture.  If a latent ignition source were to exist in a tank, the proposed techniques would not prevent an ignition."  While the FAA decided not to act on the NTSB recommendations, the FAA is  working with Boeing and other manufacturers on the wiring issues discussed earlier in the report.  An FAA advisory panel is expected to issue a report later this month that will further examine these issues.

 My investigation uncovered no evidence to contradict or counter the NTSB's assertion that the initiating event was the explosion of the CWF tank.  Boeing concurs with the NTSB's findings relative to the initiating event of the break-up of Flight 800.
 
 
 
 
 
 
 
 
 
 

VI.  THE BREAK-UP SCENARIO

 The NTSB postulates that when Flight 800 reached an altitude of approximately 13,800 feet, its CWF tank exploded.  Immediately following this explosion the nose of the airplane broke off from the fuselage.  At this point the airplane gained altitude, climbing an additional two to four thousand feet.  The airplane then began a spiraling descent.  During the descent the left wing broke off igniting the wing's fuel tank.  The airplane then erupted into a fireball which plummeted into the ocean.

 As noted earlier, the CIA and NTSB prepared an animation of the event.  The NTSB's break-up scenario is based on a careful analysis of eyewitness statements, information from the flight data recorder, radar data, wreckage location, aerodynamic principles and simulation tests.  According to the NTSB, both the CIA and NTSB simulations "...show a climb, that corrected for viewing angle, would appear to be about 45 degrees...The exact flight path of the airplane cannot be determined from either of the simulations, but both approaches are valid to show that the airplane most likely climbed a substantial amount, probably to somewhere between 15,000 and 17,000 feet in altitude."

 The break-up scenario is crucial in addressing the issue of the eyewitness testimony.  The scenario explains why so many witnesses say they saw a streak of light ascending in the sky.  From a distance of eight to ten miles, after the initiating event, Flight 800 would have resembled a streak of light ascending in the sky.  As noted earlier, the NTSB's break-up scenario is, for the most part, consistent with the bulk of the eyewitness testimony.  It is also consistent with the radar data, flight data recorder information and debris field analysis.  It is important to note that Boeing's engineers concur with the NTSB's break-up scenario.
 
 
 
 
 
 
 
 

VII.  INVESTIGATING MAJOR AIR DISASTERS

 My investigation did reveal some problems in the manner in which the federal government investigates major airline accidents.  The first problem involved the tension between the FBI and the NTSB early on in the investigation.  Such tension is to be expected when two major agencies with different missions and operating procedures are forced to work together on such a high profile investigation.  I found that, early on in the investigation, there was a communication problem between certain FBI and NTSB investigators.  There were certain instances in which the FBI sent pieces of wreckage out of the Calverton facility for further analysis without notifying some of the parties.  I was informed of only one major incident in which a piece of wreckage was taken out of Calverton by the FBI for further analysis without informing the NTSB.  That situation was immediately addressed.

 Some of the tension resulted from inadequate consultation between the FBI and other parties to the investigation, such as TWA.  However, with the exception of TWA, none of the other parties expressed to me or my staff that they were in any way hindered in their investigation of the wreckage.

 As noted earlier, it probably would have been prudent for NTSB staff to accompany the FBI on the eyewitness interviews.  I also took issue with the FBI's tortured reasoning for not making public the eyewitness statements and other evidence.  The FBI's refusal, to this day, to make this information public has only furthered the cause of the conspiracy theorists and others who have questioned the integrity of the government's Flight 800 investigation.

 My review found that in every instance in which the FBI sent wreckage out of Calverton to be analyzed, the wreckage was returned.  There was a special room at Calverton for certain pieces of wreckage the FBI found suspicious.  NTSB investigators had full access to this wreckage, as did the other parties.

 I did find, however, that the NTSB, initially, did not work as closely with the other parties, particularly Boeing, as it could have.  I was unable to determine whether this lack of close cooperation was caused by operational/institutional practices or personality problems.  But it was clear to me that the NTSB could have made better use, early on, of the other parties' knowledge and expertise.  In fairness to the NTSB, it should be noted that the traditional party procedures were not followed initially in the Flight 800 investigation because of the parallel criminal investigation being conducted by the FBI.  The initial withholding of certain information by the FBI did cause some misunderstanding and tension among the parties early on in the investigation.

 My findings in this area were substantiated by the findings of the National Civil Aviation Review Commission.  The commission's December 1997 report noted that "the accident investigation process could be improved and given even greater credibility than it now has by using outside experts or ‘parties' to a greater extent in the analytical process of determining an accident's cause."

 To its credit, the NTSB has acknowledged these problems, and has worked to forge a closer relationship with the other parties, especially Boeing.

 Perhaps what is needed is a standing protocol, or memorandum of understanding between the NTSB, airline operators, airplane manufacturers and the Airline Pilots Association on how to proceed in a major airline accident investigation.  Such an arrangement would make clear that there is to always be a high level of cooperation and understanding among all the parties in a major airline accident investigation.  Such an MOU should include some type of an agreement on the part of the NTSB not to make public any theories about probable cause without first consulting with all the parties.

 Early on in the Flight 800 investigation, NTSB officials went public with certain theories about what may have caused the explosion of the CWF tank.  These public utterances were made without consultation with the other parties.  Upon discussion and analysis with the parties, many of these theories were proven to be not feasible.  In hindsight, the NTSB probably should have consulted with Boeing and the other parties before going public with any theories.

 I was also concerned over some of the public comments made by one of the NTSB's lead investigators about a year after the accident.  The comments included assertions that the initiating event of the Flight 800 crash was a fuel air explosion in the CWF tank, and the crash could have been avoided.  While these comments were based on factual evidence uncovered to date, they were in variance to public comments made at the same time by NTSB chairman Jim Hall.  It sent a confusing message when the NTSB's lead investigator stated publicly that the break-up of the airplane was initiated by a fuel air explosion that could have been avoided, and the NTSB chairman, during the same time frame, testified to Congress that investigators were still not certain what caused the crash, and were still actively investigating all possibilities.

 My own review indicates that very early on in the investigation, once most of the wreckage was recovered, it became clear to investigators that there was no evidence of a bomb or a missile, and mechanical malfunction was probably the cause of the accident.  It should also be emphasized that following these public comments, the NTSB and FBI continued to actively investigate numerous scenarios involving a missile strike or a bomb attack.  In the final analysis, the variance between the public comments made by the NTSB's lead investigator and the NTSB's chairman did not compromise the NTSB investigation.  However, at that point in time, the NTSB should have been speaking with one voice.  In fact, I am of the opinion that in an investigation as sensitive and large as Flight 800, the only official from the NTSB who should be making public statements is the chairman.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

VIII.   RECOMMENDATIONS

As a result of my ten-month review, I am making the following recommendations to the Subcommittee:

  Enactment of legislation either directing or encouraging the NTSB to strengthen their existing procedures for investigating major airline accidents by signing a general memorandum of understanding with airplane manufacturers, airline operators, airplane pilots and other designated parties, to provide specific guidelines on how major airline accidents will be investigated.  The goal of the MOU should be to allow the NTSB to make better use of the analytical expertise of private parties – without compromising the NTSB's independence.  It should be noted that the NTSB is currently working with the Rand Corporation to address these same issues.

  Enactment of legislation either requiring or encouraging the NTSB to continue their standing policy of not making any public statements about probable cause or causes of a major airline accident unless all parties to an investigation are notified of such statements and have had a chance to provide comments.  Unfortunately, this policy was not always adhered to during the Flight 800 investigation.

  Enactment of legislation ensuring that the NTSB has full and immediate access to the information developed by any parallel federal investigation of a major airline accident, criminal or otherwise.

  A letter signed by all members of the Aviation Subcommittee, as well as the chairman and ranking member of the full committee, to the FBI urging that all of the eyewitness statements and other evidence compiled in the Flight 800 investigation be made public in a responsible manner.

  A hearing by the Aviation Subcommittee should be held to examine all of the issues outlined in this report.