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ABOUT 1117:38 PACIFIC DAYLIGHT TIME, ON AUGUST 24, 1984, WINGS WEST AIRLINES, FLIGHT 628, A BEECH C-99 (N6399U) AND AESTHETEC INC., ROCKWELL COMMANDER 112TC, N112SM, COLLIDED IN MIDAIR NEAR SAN LUIS OBISPO, CALIFORNIA. THE WEATHER AT THE TIME OF THE COLLISION WAS CLEAR. FLIGHT 628 HAD JUST DEPARTED SAN LUIS OBISPO COUNTY AIRPORT EN ROUTE TO SAN FRANCISCO INTERNATIONAL AIRPORT, CALIFORNIA, AND WAS CLIMBING ON A WESTBOUND HEADING. THE ROCKWELL COMMANDER HAD DEPARTED PASO ROBLES, CALIFORNIA, ON A TRAINING FLIGHT AND WAS DESCENDING TOWARD THE SAN LUIS OBISPO COUNTY AIRPORT ON AN EASTBOUND TRACK. THE AIRPLANES COLLIDED HEAD-ON AT AN ALTITUDE OF ABOUT 3,400 FEET. THE WRECKAGE OF BOTH AIRPLANES FELL INTO AN OPEN FIELD ABOUT 8 NMI WEST NORTHWEST OF THE SAN LUIS OBISPO COUNTY AIRPORT. ALL 17 PERSONS, INCLUDING THE 2 PILOTS AND 13 PASSENGERS ONBOARD FLIGHT 628 AND THE 2 PILOTS ONBOARD THE ROCKWELL, WERE KILLED.
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE AN AIR CARRIER OPERATIONS BULLETIN TO REQUIRE CERTIFICATED AIR CARRIERS, WHEN CONDUCTING PASSENGER REVENUE OPERATIONS, TO COMPLY WITH THE TRAFFIC ADVISORY PRACTICES AT UNCONTROLLED AIRPORTS AS RECOMMENDED IN THE AIRMAN'S INFORMATION MANUAL.
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
In the subject accident, the pilots of both airplanes failed to follow the recommended communications and traffic advisory practices in the Airman's Information Manual. The object of this recommendation was for the FAA to require pilots to establish radio contact with the controlling facility when operating VFR and thus take advantage of the air traffic advisory services available to VFR aircraft. The FAA's response again places emphasis on cockpit vigilance, which is not the object of this recommendation. In view of the FAA's reluctance to fulfill the intent of this recommendation, we have classified Safety Recommendation A-85-59 as "Closed--Unacceptable Action."
THE FAA HAS REVIEWED ITS POSITION WITH REGARD TO THIS RECOMMENDATION. I CONTINUE TO BELIEVE THAT THE ACTION CITED IN MY APRIL 21, 1986, LETTER ADDRESES THIS RECOMMENDATION COMPLETELY. THE FAA'S ACTION LETTER DATED NOVEMBER 7, 1984, DIRECTS THE PRINCIPAL OPERATIONS INSPECTORS TO ENSURE THAT THEIR CARRIERS' TRAINING PROGRAMS, OPERATIONS MANUALS, AND/OR BULLETINS EMPHASIZE THE IMPROTANCE OF COCKPIT VIGILANCE. THIS ACTION LETTER REMAINS IN EFFECT AND SPECIFICALLY CALLS ATTENTION TO AIR CARRIER OPERATIONS BULLETIN (ACOB) NO. 8-78-3, IMPORTANCE OF COCKPIT CREWMEMBERS EXTERNAL VIGILANCE. IN ADDITION TO SPECIFICALLY CITING REFERENCES IN THE AIRMAN'S INFORMATION MANUAL (AIM), ACOB NO. 8-78-3 EMPHASIZES SEE AND AVOID CONCEPTS, SCANNING TECHNIQUES, CLEARING PROCEDURES, USES OF COMMUNICATIONS EQUIPMENT, AND THEIR AIR TRAFFIC ADVISORY SERVICE. THIS ACOB ALSO REFERNCES AC 90-48, PILOTS ROLE IN COLLISION AVOIDANCE. THE BASIC AC HAS BEEN REVISED THREE TIMES AND IS NOW AC 90-48C. THE REVISIONS SPECIFICALLY ADDRESS COMMUNI CATIONS AND AIR TRAFFIC ADVISORY SERVICE PROCEDURES THAT THE SAFETY BOARD WANTS TO BE COMMUNICATED TO THE PILOT COMMUNI TY. CONSEQUENTLY, THE INFORMATION CONTAINED IN BOTH THE AIM AND AC 90-48C, AS WELL AS THE INSTRUCTIONS TO THE PRINCIPAL OPERATIONS INSPECTORS, ARE ALREADY ESTABLISHED IN THE DOCUMENTS AND PROCEDURES OF FAA DISTRICT OFFICES. THE ISSUANCE OF ANOTHER ACOB TO DESCRIBE PROCEDURES WHICH ARE ALREADY ESTABLISHED IN THE DOCUMENTS AND PROCEDURES OF FAA DISTRICT OFFICES. THE ISSUANCE OF ANOTHER ACOB TO DESCRIBE PROCE DURES WHICH ARE ALREADY DISTRIBUTED TO FAA INSPECTORS AND CERTIFICATED AIR CARRIERS IS BOTH UNNECESSARY AND REDUNDANT. I PLAN NO FURTHER ACTION ON THIS RECOMMENDATION. ON NOVEMBER 7, 1984, THE FAA TRANSMITTED AN ACTION LETTER TO ALL REGIONAL FLIGHT STANDARDS DIVISION MANAGERS. THIS LETTER DIRECTED THE PRINCIPAL OPERATIONS INSPECTORS TO ENSURE THAT THEIR CARRIERS' TRAINING PROGRAMS, OPERATIONS MANAUALS, AND/OR BULLETINS EMPHASIZE THE IMPORTANCE OF COCKPIT VIGILANCE. AIR CARRIER OPERATIONS BULLETIN (ACOB) NO. 8-783, IMPORTANCE OF COCKPIT CREWMEMBER EXTERNAL VIGILANCE, ADDRESSES THE NEED FOR COMPLIANCE WITH THE AIRMAN'S INFORMATION MANUAL.
In our recommendation letter we expressed concern that pilots may be conducting or practicing instrument approaches and departures at uncontrolled airports without communicating with an ATC facility and without broadcasting their intentions on the UNICOM frequency. We requested the FAA to require pilots to adhere to the recommended communications and traffic advisory procedures for the conduct of practice instrument approaches at uncontrolled airports as contained in the AIM. As you are aware, the basic AIM contains a section dealing with services available to pilots, including information on VFR advisory services, radar traffic information services for VFR pilots, and recommended traffic advisory practices at nontower airports. The FAA letter of November 7, 1984, addressed to All Regional Flight Standards Division Managers, and Air Carrier Operations Bulletin (ACOB) No. 8-78-3 of December 11, 1978, both emphasize external vigilance and refer to Advisory Circular 90-48 which was canceled and changed by the FAA a few years ago. We request the FAA to reconsider the issuance of a ACOB as recommended and incorporate the information pertaining to communications and air traffic advisory service procedures described in the FAA's AC No. 90-48C dated March 18, 1983. This recommendation has been classified as "Open--Unacceptable Action," pending further response.
ON 11/7/84, THE FAA TRANSMITTED AN ACTION LETTER (COPY ENCLOSED) TO ALL REGIONAL FLIGHT STANDARDS DIVISION MANAGERS. THIS LETTER DIRECTED THE PRINCIPAL OPERATIONS INSPECTORS TO ENSURE THAT THEIR CARRIERS' TRAINING PROGRAMS, OPERATIONS MANUALS, AND/OR BULLETINS EMPHASIZE THE IMPOR TANCE OF COCKPIT VIGILANCE. AIR CARRIER OPERATIONS BULLETIN (ACOB) NO. 8-78-3, IMPORTANCE OF COCKPIT CREWMEMBER EXTERNAL VIGILANCE (COPY ENCLOSED), ADDRESSES THE NEED FOR COMPLIANCE WITH THE AIRMAN'S INFORMATION MANUAL.
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