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Safety Recommendation Details

Safety Recommendation A-86-077
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 THE CENTER WEATHER SERVICE UNIT METEOROLOGIST TO DISSEMINATE INFORMATION ON RAPIDLY DEVELOPING HAZARDOUS WEATHER CONDITIONS, SUCH AS THUNDERSTORMS AND LOW-ALTITUDE WINDSHEAR, TO FEDERAL AVIATION ADMINISTRATION TERMINAL RADAR APPROACH CONTROL AND/OR TOWER FACILITIES IMMEDIATELY UPON DETECTION OF THE CONDITIONS.
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: 1/19/1990
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service (Closed - Unacceptable Action)
Keyword(s): Air Traffic Control, Weather

Safety Recommendation History
From: NTSB
To: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Date: 1/19/1990
Response:

From: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
To: NTSB
Date: 7/22/1988
Response: A RECENT SURVEY OF OUR CWSU OFFICES INDICATES THAT THE CWSU METEOROLOGIST DISSEMINATES HAZARDOUS WEATHER INFORMATION TO DESIGNATED FAA FACILITIES IN THE MOST EXPEDITIOUS MANNER. THE TELEPHONE IS USED WHEN IT IS DETERMINED THAT THIS MEANS OF COMMUNICATION IS THE MOST EFFECTIVE FOR A GIVEN SITUATION.

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: CONSIDERABLE EFFORT IS BEING EXPENDED BY THE FAA IN PLANNING FOR THE PROVISION OF TECHNOLOGICALLY ADVANCED APPARATUS FOR CWSU'S. THIS MATTER IS ALSO DISCUSSED IN RESPONSE TO SAFETY RECOMMENDATION A-86-78. ULTIMATELY, THE AVAILIBILITY OF DOPPLER RADAR DATA OFFERS THE ONLY HOPE OF MEETING THE INTENT OF THIS RECOMMENDATION. EVEN IN THIS CIRCUMSTANCE, THE NWS WILL CONTINUE TO RELY HEAVILY ON THE JUDGEMENT OF THE FORECASTER TO INTERPRET AVAILABLE WEATHER INTELLIGENCE AND DISSEMINATE WEATHER INFORMATION IN A PRUDENT AND EFFICIENT MANNER.

From: NTSB
To: FAA
Date: 2/25/1988
Response: We are not aware of any procedures which require the CWSU meteorologist to notify Terminal Radar Approach Control and/or tower facilities of rapidly developing hazardous weather conditions immediately upon detection of the conditions. For instance, information on a rapidly developing thunderstorm near a major airport need not be disseminated immediately to radar approach or tower facilities. This recommendation was also discussed at the joint staff meeting. We were informed that there were no procedures in effect that would satisfy this recommendation; neither were any new procedures deemed warranted. Therefore, based on our previous responses and the December 16, 1987, staff meeting, this recommendation is also classified as "Closed--Unacceptable Action."

From: FAA
To: NTSB
Date: 10/13/1987
Response: Current CWSU procedures provide for the timely and accurate dissemination of weather information within existing capability. The provision of immediate advisories from the CWSU to the terminal facilities, and ultimately to the pilot, is limited by the lack of a high-speed, automated dissemination system. This problem has been identified previously and can best be resolved by getting the information directly to the pilot without a middleman in the process, which is the goal of the FAA's weather program. Tasking the CWSU meteorologist with the responsibility for providing immediate terminal weather advisories would impose a major additional workload that could not be accommodated within existing resources. The FAA and NWS are both working to improve the system for timely dissemination of hazardous weather information to the pilot but, until the controller is removed from this process, some delays will be encountered. The implementation of the National Data Interchange Network, Central Weather Processor, and Mode S Data Link programs will help to resolve existing limitations. With regard to low altitude wind shear, the terminal facilities are capable of providing better advisories than the CWSU meteorologist. The Low Level Wind Shear Alert System is designed to provide real- time information on potentially hazardous surface wind conditions (on or near the airport) to the terminal controller for direct dissemination to the pilot. 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: As noted in the Board's investigation of the subject accident, the current dissemination of information on rapidly developing weather conditions to the FAA Terminal Approach Control and/or tower facilities does not provide sufficient and timely notification to pilots. It is the Board's opinion that while the Center Weather Service Unit (CWSU) meteorologist may not be able to detect windshear, at least in the subject accident he should have been able to report the rapidly changing nature of the storm, its intensity, and its proximity to the airport to the control tower. Therefore, the Safety Board requests that the FAA reconsider its position on this issue or provide the Board with copies of the current CWSU procedures which the FAA believes comply with the intent of this recommendation. Safety Recommendation A-86-77 has been classified as "Open--Unacceptable Action."

From: FAA
To: NTSB
Date: 12/16/1986
Response: THE FAA AND THE NWS ARE CONTINUALLY WORKING TO IMPROVE THE SYSTEM FOR TIMELY DISSEMINATION OF HAZARDOUS WEATHER INFORMATION TO PILOTS. THE PROCEDURES GOVERNING THE OPERATION OF THE CWSU HAVE BEEN DEVELOPED TO ENSURE THE DISSEMINATION OF TIMELY AND ACCURATE WEATHER INFORMATION WITHIN EXISTING COMMUNICATIONS AND STAFFING CAPABILITIES. ...I CONSIDER THE FAA'S ACTION ON THIS RECOMMENDATION TO BE COMPLETED. INCREASED STAFFING LEVELS REFERENCED IN A-86-76 AND NEW TECHNOLOGY REFERENCED IN A-86-78 MAY IMPACT THIS RECOMMENDATION. HOWEVER, THE CURRENT CWSU PROCEDURES HAVE BEEN REVIEWED AND DO MEET THE REQUIREMENT TO DISSEMINATE HAZARDOUS WEATHER CONDITIONS IN ACCORDANCE WITH THE CAPABILITIES AND RESPONSIBILITIES OF THE CWSU.