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ON NOVEMBER 6, 1986, A PIPER PA-23 APACHE, N2185P, WAS CLEARED FOR AN INSTRUMENT LANDING SYSTEM (ILS) APPROACH TO RUNWAY 36L AT TAMPA INTERNATIONAL AIRPORT, FLORIDA. THE PILOT WAS UNABLE TO LAND DURING HIS FIRST APPROACH. ON THE SECOND APPROACH, THE APACHE TOUCHED DOWN ON TAXIWAY W, PARALLEL TO AND ABOUT 406 FEET TO THE RIGHT (EAST) OF RUNWAY 36L. AT THE SAME TIME, A PAN AMERICAN BOEING B-727 WAS PROCEEDING SOUTHBOUND ON TAXIWAY W. WHEN THE CAPTAIN OF THE B-727 WAS THE APACHE EMERGE FROM THE FOG DIRECTLY AHEAD OF HIM, HE TURNED TO THE RIGHT IN AN ATTEMPT TO AVOID THE IMPENDING COLLISION. ABOUT 2 SECONDS LATER, THE APACHE'S LEFT ENGINE STRUCK THE B-727 IN THE RADOME. TWO PASSENGERS AND A FLIGHT ATTENDANT WERE INJURED AFTER THEY EVACUATED THE AIRPLANE. THE APACHE WAS ALMOST DESTROYED AND THE PILOT, THE SOLE OCCUPANT OF THE AIRPLANE, WAS KILLED.
THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: AMEND 14 CFR 91.116 TO REQUIRE THAT, FOR INSTRUMENT APPROACHES TO RUNWAYS WITH OPERATING RUNWAY VISUAL RANGE (RVR) EQUIPMENT AT THE APPROACH END, NO PILOT MAY CONTINUE AN APPROACH PAST THE FINAL APPROACH FIX UNLESS THE RVR IS EQUAL TO OR MORE THAN THE MINIMUM VISIBILITY PRESCRIBED FOR THAT APPROACH PROCEDURE.
Original recommendation transmittal letter:
Closed - Unacceptable Action
TAMPA, FL, United States
Piper PA-23-150, N2185P and Pan American World Airways Boeing 727-235, N4743
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Safety Recommendation History
Although specific guidance and requirements on operations below decision height or minimum descent altitude are contained in 14 CFR 91.116, we maintain the position that when RVR equipment is installed and operating, it should be considered sufficiently accurate to be the criteria for initiating an approach. The fact that an experienced, well-trained professional pilot failed to execute a successful landing emphasizes the validity of this recommendation. In view of the FAA's strong disagreement with this recommendation, we are classifying it as "Closed-- Unacceptable Action." However, we intend to monitor this recurring problem and resubmit this recommendation if accident circumstances justify.
THE FAA HAS REVIEWED ITS PREVIOUS POSITION AND DOES NOT CONCUR WITH THIS RECOMMENDATION. SPECIFIC GUIDANCE AND REQUIREMENTS ON OPERATIONS BELOW DECISION HEIGHT OR MINIMUM DESCENT ALTITUDE ARE CONTAINED IN 14 CFR 91.116. PARAGRAPH(C) (3) OF 14 CFR 91.116 PROVIDE GUIDANCE TO THE PILOT ABOUT WHAT VISUAL REFERENCES ARE REQUIRED BEFORE DESCENT IS PERMITTED BELOW THE MINIMUM ALTITUDE. ANY OPERATION TO THE CONTRARY OF THIS REGULATION IS A VIOLATION. THE FAA AGREES WITH THE BOARD'S LETTER THAT THIS ACCIDENT WOULD NOT HAVE OCCURRED IF THE DESCENT BELOW DECISION HEIGHT WITHOUT THE REQUIRED VISUAL REFERENCES. THE SAFETY BOARD STATED FURTHER THAT THIS ACCIDENT, AS INDICATED BY THE BOARD'S ANALYSIS, IS NOT THE RESULT OF INADEQUATE REGULATIONS, BUT RATHER HUMAN PERFORMANCE FACTORS WHICH COMPELLED THE PILOT TO ATTEMPT A LANDING IN SPITE OF THE EXISTING VISIBILITY CONDITIONS.
The Safety Board continues to disagree with the FAA on this issue. We have addressed this issue and the problem of the inconsistency between Part 91 and Parts 121 and 135 in the past with no success. We believe it necessary to point out that in issuing Safety Recommendation A-87-90, the Safety Board has reduced the number of runways that would be covered by the recommended amendment to Part 91. We have moved away from addressing all runways (A-82-30) to addressing only runways having RVR equipment. The FAA continues to believe that the accidents cited in the Safety Board's letter of recommendation do not support any amendment to 14 CFR 91.116. We have classified A-87-90 as "Open--Unacceptable Action" and urge you to reconsider the need to bring Part 91 into conformity with Parts 121 and 135 with regard to minimum visibility for approach procedure.
THE FAA HAS REVIEWED A-87-90 AND PREVIOUS RESPONSES TO A-82-30. THE FAA CLAIMS THAT THE INTENT OF THESE TWO SAFETY RECOMMENDATIONS IS IDENTICAL. THE FAA EVALUATION OF THE ACCIDENT AT TAMPA INTERNATIONAL AIRPORT, AS WELL AS THE STUDY DONE IN CONNECTION WITH A-82-30, DOES NOT SUPPORT AN AMENDMENT TO 14 CFR 91.116 AND, CONSEQUENTLY, THE FAA DOES NOT CONCUR WITH A-87-90. THE PREVIOUS ANALYSIS OF 19 APPROACH ACCIDENTS CITED BY THE SAFETY BOARD IN SUPPORT OF A-82-30 REVEALED THAT ONLY TWO ACCIDENTS INVOLVED CONTROLLED COLLISIONS WITH THE GROUND DURING INSTRUMENT APPROACHES, UNDER NORMAL CONDITIONS, TO AIRPORTS WHERE VISIBILITY WAS BELOW THE APPROACH MINIMUM. INVESTIGATIONS INDICATE THAT ACCIDENTS DO OCCUR WHEN PILOTS DESCEND, EITHER INADVERTENTLY OR INTENTIONALLY, BELOW MINIMUM ALTITUDES DURING INSTRUMENT APPROACHES. HOWEVER, THE NUMBERS OF ACCIDENTS WHERE THESE FACTORS ARE PRESENT -- DESCENT BELOW MINIMUM ALTITUDE WHEN THE PRESCRIBED VISIBILITY IS LESS THAN IS REQUIRED FOR THE PROCEDURE--ARE VERY LOW. JUST AS SIGNIFICANT IS THE FACT THAT 14 CFR 91.116(C)(3) ALREADY PROVIDES SPECIFIC GUIDANCE TO THE PILOT ABOUT WHAT VISUAL REFERENCES ARE REQUIRED BEFORE DESCENT IS PERMITTED BELOW THE MINIMUM ALTITUDE. AS THE SAFETY BOARD'S LETTER STATES, THIS ACCIDENT WOULD NOT HAVE OCCURED IF THE PILOT HAD OBSERVED THE EXISTING REGULATIONS WHICH PROHIBIT DESCENT BELOW DECISION HEIGHT WITHOUT THE REQUIRED VISUAL REFERENCES. IN FACT, TWO GENERAL AVIATION PILOTS MADE INSTRUMENT APPROACHES TO TAMPA JUST BEFORE THE ACCIDENT AIRCRAFT. EACH PILOT COMPLIED WITH THE REGULATIONS AND MADE MISSED APPROACHES. THIS ACCIDENT, AS INDICATED BY THE SAFETY BOARD'S ANALYSIS, IS NOT THE RESULT OF INADEQUATE REGULATIONS, BUT RATHER HUMAN PERFORMANCE FACTORS WHICH COMPELLED THE PILOT TO ATTEMPT A LANDING IN SPITE OF THE EXISTING VISIBILITY CONDITIONS. FOR THESE REASONS, FAA DOES NOT BELIEVE RULEMAKING ACTION IS WARRANTED.
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