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ON AUGUST 24, 1984, WINGS WEST AIRLINES, INC., FLIGHT 628, A BEECH C99, N6399U, AND A ROCKWELL AERO COMMANDER 112TC, N112SM, COLLIDED IN MIDAIR NEAR SAN LUIS OBISPO, CALIFORNIA. THE TWO CREWMEMBERS AND 13 PASSENGERS ABOARD WINGS WEST FLIGHT 628, AND THE TWO PILOTS ABOARD THE AERO COMMANDER WERE KILLED IN THE CRASH. PRELIMINARY ANALYSIS OF THE NATIONAL TRANSPORTATION SAFETY BOARD'S ONGOING INVESTIGATION OF THIS ACCIDENT INDICATE THAT FLIGHT 628 WAS PROCEEDING OUTBOUND FROM THE SAN LUIS OBISPO COUNTY AIRPORT ON A "CREPE ONE" DEPARTURE, WHICH REQUIRES DEPARTING TRAFFIC TO CLIMB TO CREPE INTERSECTION ON THE SAN LUIS OBISPO LOCALIZER COURSE BEFORE TRANSITIONING TO THE EN ROUTE FLIGHT PLAN. THE SAFETY BOARD'S INVESTIGATION TO DATE ALSO INDICATES THAT THE AERO COMMANDER WITH A FLIGHT INSTRUCTOR GIVING AN AIRCRAFT CHECKOUT TO ANOTHER RATED PILOT WAS PROCEEDING INBOUND TO SAN LUIS OBISPO COUNTY AIRPORT ON THE LOCALIZER COURSE TO RUNWAY 11, AND MAY HAVE BEEN MAKING A PRACTICE LOCALIZER APPROACH. CONSEQUENTLY, THE FLIGHT PATHS OF THE TWO AIR PLANES WERE DIRECTLY OPPOSED.
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REQUIRE THAT THE INSTRUMENT APPROACH CHART FOR THE LOCALIZER APPROACH TO RUNWAY 11 AT SAN LUIS OBISPO COUNTY AIRPORT AND THE CREPE ONE DEPARTURE CHART INCLUDE A CAUTIONARY NOTE WITH APPROPRIATE COMMUNICATION FREQUENCIES ADVISING VFR FLIGHTS ON PRACTICE INSTRUMENT APPROACHES AND DEPARTURES TO CONTACT LOS ANGELES CENTER FOR TRAFFIC ADVISORIES.
Original recommendation transmittal letter:
Closed - Unacceptable Action
SAN LUIS OBISPO, CA, United States
Midair Collision of Wings West Airlines Beech C-99 (N6399U) and Aesthtec, Inc., Rockwell Commander 112TC N112SM
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Safety Recommendation History
The Safety Board continues to believe that a cautionary note should be added to the appropriate charts for San Luis Obispo County Airport which would advise VFR flights on practice instrument approaches and on departures to contact Los Angeles ARTCC for traffic advisories. The note added to the charts does not do this. Again, the conclusion reached in the report of this accident is that the pilots' ability to see and avoid each other is quite marginal under these circumstances and dictates the need for more positive measures to prevent midair collisions. The note advising pilots to "watch for opposing traffic" does not make the point that "see-and-avoid" is of limited utility in such marginal conditions. The ability of an ATC controller to prevent such accidents would be greatly enhanced by knowledge of the presence of an airplane conducting practice approaches as contemplated by the Board's recommendation. As an impasse has been reached in discussion of this recommendation, Safety Recommendation A-84-126 has been classified as "Closed-- Unacceptable Action." Although this recommendation has been closed the Safety Board will continue to stress this issue in further accident investigations and other studies.
I AGREE THAT IT IS IMPORTANT THAT A PILOT CONTACT THE CONTROLLING AIR TRAFFIC FACILITY FOR TRAFFIC AND OTHER PERTINENT ADVISORIES. THIS SPECIFIC SUBJECT IS ADDRESSED IN PARAGRAPH 244 OF THE AIRMAN'S INFORMATION MANUAL AND AS PART OF THE INSTRUMENT FLIGHT INSTRUCTION. FURTHERMORE, THE FREQUENCY OF THE LOS ANGELES AIR ROUTE TRAFFIC CONTROL CENTER IS LISTED ON THE SIAP CHART FOR THE SAN LUIS OBISPO PROCEDURE. CONSEQUENTLY, I DO NOT BELIEVE THAT AN ADDITIONAL ADVISORY NOTE ON THE FACE OF THE SIAP IS NECESSARY FOR THE PROPER UNDERSTANDING OF THE APPROACH PROCEDURE. ADDITIONALLY, THESE ADVISORY NOTES WOULD ADD EXTRANEOUS INFORMATION TO AN ALREADY CROWDED CHART.
The FAA responded that it concurred, in part, with the recommendation and that it had initiated a program to include a "note" on each of the subject charts to read, "During VFR conditions, watch for opposing traffic on the localizer." The FAA also responded that the appropriate communications frequencies now are on the charts. Beyond the action taken by the FAA, the Safety Board recommended that the "cautionary" note advise VFR flights on practice instrument approaches and on departures to contact Los Angeles ARTCC for traffic advisories. The note added to the chart does not do this. Again, the conclusion reached in the report of this accident that the pilots' ability to see and avoid each other is quite marginal under these circumstances dictates the need for more positive measures to prevent midair collisions. The note advising pilots to "watch for opposing traffic" does not reach the point that "see-and-avoid" is of limited utility in such marginal conditions. The ability of an ATC controller to prevent such accidents would be greatly enhanced by knowledge of the presence of an airplane conducting practice approaches as contemplated by the Board's recommendation. Consequently, Safety Recommendation A-84-126 has been classified as "Open--Unacceptable Action" pending reconsideration by the FAA. Further, the Safety Board believes that similar hazardous situations may exist at other uncontrolled airports served by air carriers and the FAA should take similar steps to improve safety of operations at those airports.
FAA LTR: THE FAA PLANS TO ADD THE FOLLOWING NOTE TO THE SAN LUIS OBISPO SID AND SIAP CHARTS, "DURING VFR CONDITIONS WATCH FOR OPPOSING TRAFFIC ON LOCALIZER," COMMUNICATION FREQUENCIES WILL NOT BE INCLUDED IN THE NOTE.
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