Eerie Questions Linger After Tragedy -- Parents Of Passenger Who Died Don't Accept New Ntsb Findings

The National Transportation Safety Board yesterday blamed United Airlines, Boeing and the Federal Aviation Administration for the tragedy of United Flight 811.

But for the Campbell family of Wellington, New Zealand, the safety board's ruling raises more questions than it answered.

The safety board said probable cause of the accident was ``the sudden opening of the improperly latched'' forward cargo door. The 9-foot-square, 800-pound door tore open a gaping hole in the Boeing 747-100, hurtling 24-year-old Lee Campbell and eight other passengers to their deaths.

The accident occurred shortly after Flight 811 left Honolulu and was climbing past 22,000 feet bound for Australia and New Zealand. The pilot nursed the crippled aircraft safely back to Honolulu.

According to the safety board, factors contributing to the accident included:

-- Boeing's ``deficiency in design of the cargo door locking mechanisms,'' which made the locks ``susceptible to damage'' by ground workers and ``allowed the door to be unlatched, yet to show a properly latched and locked position.''

-- Boeing and the FAA failing to take ``timely corrective action,'' in light of a 1987 incident in which a Pan Am 747 cargo door opened in mid-flight.

-- A ``lack of proper maintenance and inspection of the cargo door'' by United.

Significantly, United ground worker Brian Kitaoka testified that he used the system of electrical motors built into the plane to close, latch and lock the door before takeoff, and that there was nothing unusual about the 15-second closing sequence.

Moreover, the flight crew corroborated Kitaoka by testifying that no cockpit warning lights to indicate an improperly shut cargo door were illuminated prior to the ``explosive decompression'' of the aircraft. Investigators later confirmed that the warning light system was functioning properly.

Yet the safety board concluded that the door, somehow, was improperly latched when the plane took off.

``What they're saying is wrong, provably wrong,'' Kevin Campbell said in a telephone interview from his Wellington home yesterday.

Campbell, 46, is not second-guessing the safety board on a whim. He and his wife, Susan, have spent $100,000 and virtually every waking minute since the Feb. 24, 1989, accident trying to figure out why their eldest son died.

They've made five trips to the U.S., poked through and photographed the damaged aircraft, attended the safety board's hearings in Seattle, interviewed the flight crew, pored over 5,000 pages of NTSB documents and corresponded with experts and survivors. Lately, they've spent a lot of time relating the tale of their extraordinary quest to the international media.

NTSB spokeswoman Drusella Andersen said yesterday that the safety board considered - and rejected - the Campbells' theory.

But that hasn't stopped the retired car dealer from laying plans to accompany the U.S. Navy this summer when it attempts to retrieve the cargo door from an ocean depth of about three miles.

Campbell agrees with the safety board on one thing - that the door contains evidence that could prove conclusively what happened.

Campbell, for one, is convinced that the forward cargo door on Flight 811 was, indeed, closed, latched and locked properly before takeoff.

He has deduced that a stray spurt of electricity - perhaps from frayed wiring inside the door, perhaps from a burst of lightning the plane was flying through at the time - brought the door's electrical latching motors spontaneously whirring to life soon after the plane took off.

Boeing concurs with the safety board in refuting Campbell's theory. Said spokesman Jack Gamble: ``The NTSB has very clearly ruled out electrical malfunction.''

Though the NTSB was not specific in its summary findings yesterday, the board appeared to imply that something else happened to Flight 811's lock sectors, something similar to what happened on Pan Am Flight 125 two years earlier.

In that incident, a Pan Am 747 cargo door eased open soon after takeoff from London. The pilot was able to return to London with no damage or injuries. The door was shut and locked again and the plane sent on its way.

Boeing, Pan Am and the FAA later concluded that Pan Am ground workers had been manually closing the doors because the electrical system was malfunctioning and, in doing so, workers used a speed wrench to rotate the latches into a closed position and then hand-cranked the lock sectors into place.

The final step in the door-closing sequence, whether manual or electric, calls for the worker to push shut a ``master lock handle.''

According to Boeing's fail-safe design, this can only be accomplished if the latches and locks have been rotated to the closed and locked position.

Authorities concluded that, as a shortcut procedure to test the positioning of the lock sectors, a Pan Am ground worker, after securing the master lock handle, supposedly ``backdrove'' the lock sectors by cranking them in reverse.

After doing this many times the lock sectors became splayed, bent and cracked to a point where backdriving them could result in them being unaligned and, therefore, no longer effective.

As a result of the Pan Am incident, the FAA in July 1988 ordered all U.S. airlines to beef up aluminum lock sectors with steel plates and required closer monitoring of the door-closing sequence. However, some airlines were given until mid-1990 to install the steel plates. Estimated cost for the work: $2,000 per plane.

United Flight 811 had aluminum lock sectors and was covered by the order, but it was scheduled to have steel plates installed in late 1989 or early 1990. After the accident, the FAA shortened the deadline for U.S. airlines to 30 days.

``Our son died for want of a $2,000 repair - and they knew about it for so long,'' Campbell said. ``The FAA has to shorten the time scale on these type of repairs. You can't make things perfectly safe, but Flight 811 was not necessary.''

Regardless of which theory ultimately proves accurate on why the door opened, Campbell contends the flying public is not out of danger yet.

To date, the 156 older-model 747s operated by 13 U.S.-registered airlines have had steel reinforced lock sectors installed per the FAA order.

However, there are 657 747s flying, most of them operated by 57 foreign carriers. Boeing's Gamble said he assumed, but could not confirm, that foreign operators are, likewise, installing steel plates in 747s that have aluminum lock sectors.

One reason Campbell thinks the authorities are wrong about Flight 811 is that he believes Boeing, the FAA and Pan Am were off base about Pan Am Flight 125, as well.

Campbell notes that the Pan Am ground worker denied backdriving the locks and that, though he search diligently, he could find no hard evidence that manual backdriving, indeed, was a common practice.

In any case, the backdriving of the locks is moot point, because it comes after the step of rotating the door latches into the closed position - and either a mechanic or the motor would have to release the latches before the door could open.

After the Pan Am incident, Boeing conducted a series of tests proving that the high-torque, electric latch motors used on 747 cargo doors, if activated out of sequence, rather easily pushed aside the aluminum lock sectors.

But Campbell contends a flaw in the official explanations of both incidents has to do with the focus on the lock sectors, when it should be on the master-lock handle and the latches.

As the last step in the closing sequence, pushing in the master-lock handle can only be accomplished if the latches and lock sectors have been rotated to the closed and locked positions.

The handle is designed to break off if the latches and locks aren't fully closed and locked. Depressing the master-lock handle also shuts two small, square panels, called pressure-relief doors, which shut off the cockpit warning lights.

Once the door latches are rotated into the closed position, electrically or manually, the door can be opened only by the reverse process.

This requires either a mechanic making 90 full turns with a speed wrench, or someone or something activating the electric latch motor.

In its explanation yesterday, the safety board seemed to imply that the master-lock handle on Flight 811 was pushed in properly as the final step in the closing sequence, turning off the cockpit lights, but that, somehow, the latches were not properly secured. There was no specific explanation from the NTSB of how that may have occurred.

Boeing spokesman Craig Martin acknowledged last year that a ``spurious electrical signal'' caused by a short circuit could, in theory, activate the latch motors.

Campbell concedes that a highly unusual sequence of circumstances would have to unfold for such a stray electrical signal to spontaneously empower the latch motors once the door-closing, latching and locking sequence has been completed.

He says the most likely scenario he can envision is a short circuit occurring between a wire leading to the latch motor and another wire that is the power source feeding some other system on the plane.

``It (the latch motor) could have picked up power from another wire in the system,'' Campbell said. ``There's loads of 115-volt power all through the aircraft.''

Campbell believes the retrieved door will show door latches rotated to the open position with the lock sectors and the master lock handle secured in the locked position.

If so, he said, the obvious conclusion is that the door was closed properly, but then a short circuit spontaneously empowered the latch motor, which then drove the latches past the weak aluminum lock sectors to the open position.

In the midst of his research, Campbell came across testimony submitted to the NTSB by passengers Roland Wilhelmy and David Birrell.

Almost eerily, the testimony of these two passengers, who were sitting on the edges of the section torn out by the cargo door, gave substance to his theory, Campbell said.

Birrell told the safety board he heard a ``mechanical noise under my feet just prior to the blowout.'' At about that same moment, Wilhelmy reported hearing a ``quiet buzzing or hissing or sound lasting about two seconds, followed immediately by decompression.''

Campbell believes the latch motor, which is designed to take 1.8 seconds to rotate the door latches to the open position, made the sounds heard by Birrell and Wilhelmy.