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Safety Recommendation Details

Safety Recommendation A-86-066
Details
Synopsis: ON AUGUST 2, 1985, AT 1805:52 CENTRAL DAYLIGHT TIME, DELTA AIR LINES (DELTA) FLIGHT 191, A LOCKHEED L-1011-385-1, N726DA, CRASHED WHILE APPROACHING TO LAND ON RUNWAY 17L AT THE DALLAS/FORT WORTH INTERNATIONAL (DFW) AIRPORT, TEXAS. WHILE PASSING THROUGH THE RAIN SHAFT BENEATH A THUNDERSTORM, FLIGHT 191 ENTERED A MICROBURST WHICH THE PILOT WAS UNABLE TO TRAVERSE SUCCESSFULLY. THE AIRPLANE STRUCK THE GROUND ABOUT 6,300 FEET NORTH OF THE APPROACH END OF RUNWAY 17L, HIT A CAR ON A HIGHWAY NORTH OF THE RUNWAY KILLING THE DRIVER, STRUCK TWO WATER TANKS ON THE AIRPORT, AND BROKE APART. EXCEPT FOR A SECTION OF THE AIRPLANE CONTAINING THE AFT FUSELAGE AND EMPENNAGE, THE REMAINDER OF THE AIRPLANE DISINTEGRATED DURING THE IMPACT SEQUENCE, AND A SEVERE FIRE ERUPTED DURING THE IMPACT SEQUENCE. OF THE 163 PERSONS ABOARD, 134 PASSENGERS AND CREWMEMBERS WERE KILLED; 26 PASSENGERS AND 3 CABIN ATTENDANTS SURVIVED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUE AN AIR CARRIER OPERATIONS BULLETIN TO DIRECT PRINCIPAL OPERATIONS INSPECTORS TO REVIEW THOSE SECTIONS OF COMPANY OPERATIONS MANUALS AND TRAINING CURRICULA PERTAINING TO THUNDERSTORM AVOIDANCE PROCEDURES TO VERIFY THAT FLIGHTCREWS CLEARLY UNDERSTAND THE POLICY THAT NO AIRCRAFT SHOULD ATTEMPT TO LAND OR TAKE OFF IF ITS FLIGHT PATH IS THROUGH, UNDER, OR NEAR (WITHIN A MINIMUM SPECIFIED DISTANCE) A THUNDERSTORM.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: DALLAS/FT WORTH, TX, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA85AA031
Accident Reports: Delta Air Lines, Inc., Lockheed L-1011-385-1, N726DA
Report #: AAR-86-05
Accident Date: 8/2/1985
Issue Date: 9/3/1986
Date Closed: 6/18/1990
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Training and Education, Thunderstorms/Rain/Snow, Flightcrew, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/18/1990
Response: Air Carrier Operations Bulletin No. 7-76-3, issued May 2, 1988, emphasizes to operations inspectors the need to ensure that air carrier training programs and operations manuals contain thunderstorm avoidance policies, incorporate meteorological training, and stress the proper use of airborne weather radar. The bulletin satisfies the recommendation. (Recommendation A-86-66, issued September 3, 1986, is reclassified as "Closed--Acceptable Action.")

From: FAA
To: NTSB
Date: 12/12/1988
Response: On May 2, 1988, the FAA issued Air Carrier Operations Bulletin No. 7-76-3, Severe Weather Training and Thunderstorm Season Preparedness. This bulletin emphasizes the summer severe storm season and serves as a reminder to all pilots of the need to review their approved flight procedures involving adverse weather, particularly thunderstorms. I have enclosed a copy of the bulletin for the Board's information. I consider the FAA's action to be completed, and I plan no further action on this safety recommendation.

From: FAA
To: NTSB
Date: 10/27/1988
Response:

From: FAA
To: NTSB
Date: 1/7/1988
Response: The Safety Board's letter dated March 20, 1987, stated that the FAA's educational and training material packages, in combination with the principal operations inspectors review of their respective air carrier's manuals and training curricula, were a reasonable approach for complying with the intent of these safety recommendations. The Safety Board classified these safety recommendations as "OPEN ACCEPTABLE ACTION" based on the FAA's action. The FAA sent a followup letter to the Safety Board on May 28, 1987, stating that it had completed its educational and training material packages and had distributed these packages to all principal operations inspectors (POI) and airlines for incorporation into training programs on low-level wind shear. The FAA's letter also stated that all POI's were being scheduled to attend a training program at the Oklahoma City training facility so that each inspector would be able to evaluate the wind shear training program of his/her assigned airline. The FAA stated that it believed its action to be completed on these safety recommendations. On August 5, 1987, the Safety Board expressed its additional concern that while the FAA indicated that all POI's will attend a training program based upon the training package, the Board is uncertain that the airlines will be required to incorporate the information into their training programs. The Safety Board believes that training on wind shear encounters should be a required item in every airline's training program. Pending the FAA's further response, these safety recommendations have been classified as "OPEN ACCEPTABLE ALTERNATE ACTION." The Safety Board's most recent concern is being addressed in response to Safety Recommendation A-85-26, which states "In cooperation with air carriers and manufacturers, develop a common wind shear training program and require air carriers to modify airline training syllabi to effect such training." In response to this safety recommendation the FAA issued a Notice of Proposed Rulemaking (NPRM) No. 79- 11A, Airborne Low-Altitude Wind Shear Equipment and Training Requirements, proposing to require wind shear training be incorporated into the ground training curricula of all 14 CFR Part 121 certificate holders and those 14 CFR Part 135 certificate holders required to have approved pilot training programs. Additionally, this NPRM proposes to require wind shear training be incorporated into the pilot flight training curricula of all 14 CFR Part 121 certificate holders operating turbine- powered airplanes. A copy of the NPRM was provided to the Safety Board in response to Safety Recommendation A-85-26. Regardless of the outcome of the rulemaking effort described above, I believe that the FAA has complied with the intent of these safety recommendations. I plan no further action in response to these safety recommendations, and I urge the Safety Board to classify these safety recommendations as "CLOSED."

From: NTSB
To: FAA
Date: 8/5/1987
Response: As stated in the Board's letter of March 20,1987, the Board would prefer that stronger action be taken. The Board believes that development of the educational and training materials package mentioned in your letter of December 16, 1986, in combination with the principal operations inspectors review of their respective air carrier's manuals and training curricula, is an excellent first step in the process of preventing windshear incursion accidents. The Board is pleased that this training package is now being distributed to all principal operations inspectors and airlines for incorporation into training programs on low-level windshear. However, while your letter indicated that all principal operations inspectors will attend a training program based upon this training package, the Board is uncertain if the airlines will be required to incorporate this information into their training programs. It is the Board's opinion that training on windshear encounters should be a required item in every airlines training program. Pending further correspondence on this issue, Safety Recommendation A-86-66 and -67 have been classified as "Open-- Acceptable Alternate Action."

From: FAA
To: NTSB
Date: 5/28/1987
Response: THE FAA HAS COMPLETED ITS EDUCATIONAL AND TRAINING MATERIAL PACKAGE DESIGNED TO MEET THE TRAINING REQUIREMENTS OF THESE RECOMMENDATIONS. THIS TRAINING PACKAGE IS BEING DISTRIBUTED TO ALL PRINCIPAL OPERATIONS INSPECTORS AND AIRLINES FOR INCORPORATION INTO TRAINING PROGRAMS ON LOW-LEVEL WINDSHEAR. ALSO, ALL PRINCIPAL OPERATIONS INSPECTORS ARE BEING SCHEDULED TO ATTEND A TRAINING PROGRAM AT THE OKLAHOMA CITY TRAINING FACILITY SO THAT EACH INSPECTOR WILL BE ABLE TO EVALUATE THE WINDSHEAR TRAINING PROGRAM OF HIS/HER ASSIGNED AIRLINE.

From: NTSB
To: FAA
Date: 3/20/1987
Response: The Safety Board has carefully considered the FAA's response to these recommendations and has concluded that the actions taken by the FAA have the potential for complying with the Board's intent. While the Board would prefer that stronger action be taken, the Board believes that development of the educational and training materials package mentioned in your letter, in combination with the principal operations inspectors review of their respective air carrier's manuals and training curricula, is a reasonable approach. Pending further correspondence on this issue, Safety Recommendations A-86-66 and -67 have been classified as "Open-- Acceptable Action."

From: FAA
To: NTSB
Date: 12/16/1986
Response: THE FAA HAS CONTRACTED WITH THE BOEING COMPANY TO DEVELOP AN EDUCATIONAL AND TRAINING MATERIALS PACKAGE SPECIFICALLY DESIGNED TO MEET THIS COMMON CONCERN. THIS PACKAGE WILL BE AVAILABLE IN FINAL FORM IN THE SPRING OF 1987 FOR INDIVIDUAL AND/OR AIR CARRIER INCORPORATION INTO RESPECTIVE TRAINING PROGRAMS. THIS TRAINING PACKAGE WILL ALSO PROVIDE CURRENT INFORMATION FOR THE UPDATE OF AC 00-50A, LOW LEVEL WINDSHEAR. I BELIEVE THAT THIS EFFORT REPRESENTS THE BEST COLLECTIVE INTELLIGENCE REGARDING WINDSHEAR THAT CAN BE OBTAINED CURRENTLY, INCLUDING ITS RECOGNITION AND AVOIDANCE AND HOW TO BEST ESCAPE FROM AN INADVERTENT ENCOUNTER. ADDITIONALLY, TO ADDRESS THE SAFETY ISSUE OF THE RECOMMENDATIONS IMMEDIATELY, THE FAA HAS ASKED ALL REGIONAL FLIGHT STANDARDS DIVISION MANAGERS TO HAVE THEIR PRINCIPAL OPERATIONS INSPECTORS REVIEW THEIR RESPECTIVE AIR CARRIERS' MANUAL AND TRAINING CURRICULA TO ENSURE THAT FLIGHT CREWMEMBERS ARE PROVIDED ADEQUATE INFORMATION IN THIS AREA.