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Safety Recommendation Details

Safety Recommendation A-86-076
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 PAS SENGERS AND 3 CABIN ATTENDANTS SURVIVED.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION AND THE NATIONAL WEATHER SERVICE: DEVELOP PROCEDURES TO REQUIRE THAT CENTER WEATHER SERVICE UNITS ARE ATTENDED CONSTANTLY DURING OPERATION SO THAT INFORMATION CONCERNING HAZARDOUS WEATHER CONDITIONS, SUCH AS THUNDERSTORMS, WIND SHEAR, ICING, AND TURBULENCE, EITHER OCCURRING OR EXPECTED TO OCCUR, RECEIVES PROMPT, APPROPRIATE DISSEMINATION.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 2/25/1988
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service (Closed - Acceptable Alternate Action)
Keyword(s): Weather, Staffing

Safety Recommendation History
From: NTSB
To: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Date: 2/16/1994
Response: THE BOARD RECENTLY RECEIVED A MEMORANDUM ROM THE NEWS FORMALIZING PROCEDURES FOR DUTY METEOROLOGISTS. THE PROCEDURES STATE THAT METEOROLOGISTS SHOULD NOT LEAVE THE CONTROL ROOM AT ANY TIME WHEN SEVERE WEATHER IS KNOW TO BE OCCURRING OR EXPECTED TO OCCUR UNLESS ANOTHER METEOROLOGIST IS AVAILABLE TO ASSUME THE WEATHER WATCH. BASED ON THIS INFORMATION, THE BOARD CLASSIFIES SAFETY RECOMMENDATION A-86-76 "CLOSED--ACCEPTABLE ALTERNATE ACTION."

From: NTSB
To: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Date: 1/9/1990
Response:

From: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
To: NTSB
Date: 7/22/1988
Response: THE FEDERAL AVIATION ADMINISTRATION (FAA) EMPLOYEE INVOLVED IN THE DISCHARGE OF THE WEATHER COORDINATOR FUNCTION, OR DESIGNEES, ARE CURRENTLY NOTIFIED WHENEVER THE CENTER WEATHER SERVICE UNIT (CWSU) METEOROLOGISTS LEAVE THE OPERATIONS AREA. THIS PROCEDURE WILL BE FORMALIZED BY THE NEWS WITHIN LOCAL CWSU STATION DUTY MANUALS.

From: NTSB
To: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Date: 10/19/1987
Response:

From: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
To: NTSB
Date: 6/4/1987
Response: NO RESPONSE RECEIVED.

From: NTSB
To: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Date: 6/4/1987
Response:

From: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
To: NTSB
Date: 6/1/1987
Response: AN INCREASE IN STAFFING LEVELS WILL BE NECESSARY TO REALIZE CONSTANT CWSU COVERAGE. IT IS MY UNDERSTANDING THAT THE FAA HAS INDICATED AN INTENTION TO MEET WITH THE NWS IN THE NEAR FUTURE TO EVALUATE THIS MATTER.

From: NTSB
To: FAA
Date: 2/25/1988
Response: Although we support increasing the staffing and operational hours of the Center Weather Service Unit (CWSU), increased manning is not the only way to satisfy this recommendation. A procedure to require coordination between the CWSU meteorologist when he or she leaves the position and the weather coordinator would be responsive to the intent of this recommendation. Prior to leaving the unit, the CWSU meteorologist would notify the weather coordinator. The weather coordinator would then monitor, in a general sense, the existing weather conditions. If the need arose, the weather coordinator could call the CWSU meteorologist back to the unit. On December 16, 1987, the Safety Board's staff met with the FAA's staff to discuss this idea. However, there was no agreement to this view. Therefore, since the FAA plans to take no further action, based on our previous responses and the negative results of the NTSB/FAA staff meeting, this recommendation is now classified as "Closed--Unacceptable Action."

From: FAA
To: NTSB
Date: 10/13/1987
Response: The operational hours and meteorologist staffing of the Center Weather Service Units (CWSU) are established to meet the requirements of the Air Route Traffic Control Center facility manager and are based upon available manpower, traffic flows, and weather considerations. Normally, prescheduled day and evening shifts are established with one meteorologist on duty. The exact hours of each shift are dependent upon anticipated weather and traffic conditions as determined by the area manager-in-charge who may request the meteorologists to adjust their normal schedule in order to accommodate the needs of the facility. When required, additional coverage may also be provided by the meteorologist-in-charge. The Weather Coordinator position is staffed continually and is responsible for the dissemination of all weather advisories during periods when a meteorologist is not manning the CWSU. A review of CWSU operations and meteorologist staffing requirements was conducted on June 18 in a joint meeting with the National Weather Service (NWS) where it was decided that, although additional system wide CWSU manning would not generate a significant improvement in the dissemination of hazardous weather information, individual requests by facility managers for increased meteorologist staffing would receive full consideration. It is also anticipated that programmed improvements in the CWSU alphanumeric and graphics processing capability will enhance the dissemination of hazardous weather information. I consider the FAA's action to be completed, and I plan no further action on this recommendation.

From: NTSB
To: FAA
Date: 3/12/1987
Response: Pending the outcome of the FAA's and the National Weather Service's (NWS) evaluation of meteorologist staffing levels, Safety Recommendation A-86-76 has been classified as "Open--Acceptable Action." The Safety Board requests that this evaluation be accomplished as quickly as possible in order that sufficient staffing be available for the next active convective weather season.

From: FAA
To: NTSB
Date: 12/16/1986
Response: PROCEDURAL CHANGES RELATED TO CWSU WILL NOT SATISFY THE INTENT OF THIS RECOMMENDATION. THE CWSU STAFFING GENERALLY ALLOWS SINGLE COVERAGE DURING THE OPERATIONAL PERIOD OF THE CWSU, AND THE METEOROLOGIST ON DUTY DOES NOT NORMALLY LEAVE THE UNIT UNATTENDED WHEN WEATHER CONDITIONS SHOW A POTENTIAL FOR RAPID CHANGE. HOWEVER, IF THE METEOROLOGIST IS REQUIRED TO BE AWAY FROM THE CWSU FOR ANY REASON, A WEATHER COORDINATOR IS ASSIGNED TO DISSEMINATE WEATHER ADVISORIES WHICH HAVE BEEN ISSUED. THIS PERSON CANNOT ANALYZE OR INTERPRET AVAILABLE WEATHER DATA TO INITIATE A WEATHER ADVISORY. AN INCREASE IN STAFFING LEVELS WILL BE NECESSARY FOR CONTINUOUS COVERAGE OF A CWSU. THE FAA, TOGETHER WITH THE NWS, WILL EVALUATE NECESSARY METEOROLOGIST STAFFING LEVELS AND ASSOCIATED COSTS. IF IT IS DETERMINED TO BE FEASIBLE, A CHANGE TO THE FAA, NOAA, NWS AGREEMENT WILL BE INITIATED.