DCA94MA065
NTSB Identification: DCA94MA065 .
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Scheduled 14 CFR USAIR
Accident occurred Saturday, July 02, 1994 in CHARLOTTE, NC
Probable Cause Approval Date: 1/19/1996
Aircraft: DOUGLAS DC-9-31, registration: N954VJ
Injuries: 37 Fatal, 16 Serious, 4 Minor.

THE AIRPLANE COLLIDED WITH TREES AND A PRIVATE RESIDENCE SHORTLY AFTER THE FLIGHTCREW EXECUTED A MISSED APPROACH FROM THE RWY 18R ILS. FLIGHTCREW WAS NOT PROVIDED UPDATED WX INFO IN ATIS;WX REFLECTED THUNDERSTORM & RAINSHOWER. TERMINAL DOPPLER WX RADAR NOT INSTALLED AT ARPT AS SCHEDULED; WOULD HAVE PROVIDED CONTROLLERS WITH INFO ABOUT SEVERITY OF WX, AND INFO WOULD HAVE BEEN BENEFICIAL TO FLIGHTCREW. INADEQ ATC PROCEDURES, BREAKDOWN IN COMM IN TOWER, PREVENTED FLIGHTCREW FROM RECEIVING ADDITIONAL CRITICAL INFO ABOUT ADVERSE WX OVER ARPT & ALONG APPROACH PATH. FLIGHT ENCOUNTERED WINDSHEAR OF 61 KTS OVER A 15 SEC PERIOD. INADEQ COMPUTER SOFTWARE DESIGN IN THE AIRPLANE'S ON-BOARD WINDSHEAR DETECTION SYSTEM PREVENTED FLIGHTCREW FROM RECEIVING MORE TIMELY WINDSHEAR ALERT. 1ST OFFICER INITIALLY ROTATED TO PROPER 15 DEG NOSE-UP ATTITUDE DURING MISSED APPROACH. HOWEVER, THRUST WAS SET BELOW STANDARD GO-AROUND EPR LIMIT OF 1.93, PITCH ATTITUDE REDUCED TO 5 DEG NOSE DOWN BEFORE FLIGHTCREW RECOGNIZED DANGEROUS SITUATION. FAA'S POI, USAIR'S MANAGEMENT, WERE AWARE OF INCONSISTENCIES IN FLIGHTCREW ADHERENCE TO OPERATING PROCEDURES WITHIN THE AIRLINE; HOWEVER, CORRECTIVE ACTIONS HAD NOT RESOLVED THIS PROBLEM.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

1) THE FLIGHTCREW'S DECISION TO CONTINUE AN APPROACH INTO SEVERE CONVECTIVE ACTIVITY THAT WAS CONDUCIVE TO A MICROBURST; 2) THE FLIGHTCREW'S FAILURE TO RECOGNIZE A WINDSHEAR SITUATION IN A TIMELY MANNER; 3)THE FLIGHTCREW'S FAILURE TO ESTABLISH AND MAINTAIN THE PROPER AIRPLANE ATTITUDE AND THRUST SETTING NECESSARY TO ESCAPE THE WINDSHEAR; AND 4) THE LACK OF REAL-TIME ADVERSE WEATHER AND WINDSHEAR HAZARD INFORMATION DISSEMINATION FROM AIR TRAFFIC CONTROL, ALL OF WHICH LED TO AN ENCOUNTER WITH AND THE FAILURE TO ESCAPE FROM A MICROBURST-INDUCED WINDSHEAR THAT WAS PRODUCED BY A RAPIDLY DEVELOPING THUNDERSTORM LOCATED AT THE APPROACH END OF RUNWAY 18R. CONTRIBUTING TO THE ACCIDENT WERE: 1) THE LACK OF AIR TRAFFIC CONTROL PROCEDURES THAT WOULD HAVE REQUIRED THE CONTROLLER TO DISPLAY AND ISSUE AIRPORT SURVEILLANCE RADAR (ASR-9) WEATHER INFORMATION TO THE PILOTS OF FLIGHT 1016; 2) THE CHARLOTTE TOWER SUPERVISOR'S FAILURE TO PROPERLY ADVISE AND ENSURE THAT ALL CONTROLLERS WERE AWARE OF AND REPORTING THE REDUCTION IN VISIBILITY AND RUNWAY VISUAL RANGE VALUE INFORMATION, AND THE LOW LEVEL WINDSHEAR ALERTS THAT HAD OCCURRED IN MULTIPLE QUADRANTS; 3) THE INADEQUATE REMEDIAL ACTIONS BY USAIR TO ENSURE ADHERENCE TO STANDARD OPERATING PROCEDURES; AND 4) THE INADEQUATE SOFTWARE LOGIC IN THE AIRPLANE'S WINDSHEAR WARNING SYSTEM THAT DID NOT PROVIDE AN ALERT UPON ENTRY INTO THE WINDSHEAR. (NTSB REPORT AAR-95/03)

Full narrative available

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