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Safety Recommendation Details

Safety Recommendation A-91-063
Details
Synopsis: ON DECEMBER 3, 1990, AT 1354 EASTERN STANDARD TIME, NORTHWEST AIRLINES (NWA) FLIGHT 1482, A MCDONNELL DOUGLAS DC-9, AND NORTHWEST AIRLINES FLIGHT 299, A BOEING 727 (B-727), COLLIDED NEAR THE INTERSECTION OF RUNWAYS 09/27 AND 03C-21C AT DETROIT METROPOLITAN/WAYNE COUNTY AIRPORT (DTW), DETROIT MICHIGAN. THE DC-9 WAS TO BE A REGULARLY SCHEDULED PASSENGER FLIGHT TO PITTSBURGH, PENNSYLVANIA, AND THE B-727 WAS TO BE A REGULARLY SCHEDULED PASSENGER FLIGHT TO MEMPHIS, TENNESSEE. BOTH AIRPLANES WERE OPERATING UNDER FEDERAL AVIATION REGULATIONS (FAR) PART 121 AND INSTRUMENT METEOROLOGICAL CONDITIONS PREVAILED AT THE TIME AT DTW. THE B-727 WAS ON ITS TAKEOFF ROLL ON RUNWAY 3C AT THE TIME OF THE COLLISION, AND THE DC-9 HAD TAXIED ONTO THE RUNWAY JUST PRIOR TO THE ACCIDENT. THE B-727 WAS SUBSTANTIALLY DAMAGED, AND THE DC-9 WAS DESTROYED DURING THE COLLISION AND SUBSEQUENT FIRE. OF THE 40 PASSENGERS AND 4 CREWMEMBERS ABOARD THE DC-9, 7 PASSENGERS AND 1 FLIGHT ATTENDANT RECEIVED FATAL INJURIES. NONE OF THE 146 PASSENGERS AND 8 CREWMEMBERS ON THE B-727 WERE INJURED.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Develop and implement procedures for redundancy of critical controller tasks, and expedite the development and installation of hardware systems to supplement such redundancy. (superseded by A-95-30, A-95-31, A-95-32)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action/Superseded
Mode: Aviation
Location: ROMULUS, MI, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA91MA010AB
Accident Reports: NW Airlines, Inc., Flights 1482 and 299 Runway Incursion and Collision
Report #: AAR-91-05
Accident Date: 12/3/1990
Issue Date: 7/23/1991
Date Closed: 2/19/1997
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action/Superseded)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/19/1997
Response: BECAUSE THE FAA IS CURRENTLY ADDRESSING THE ISSUE OF REDUNDANCIES FOR CRITICAL CONTROLLER TASKS THROUGH AUTOMATION INITIATIVES THAT HAVE BEEN CLASSIFIED AS ACCEPTABLE, SUCH AS A-95-30 THROUGH -32, THE SAFETY BOARD BELIEVES THAT IT WOULD BETTER SERVE BOTH AGENCIES TO ELIMINATE REDUNDANT DIALOGUE THAT THE FAA IS ADDRESSING THROUGH OTHER SAFETY RECOMMENDATIONS. THEREFORE, A-91-63 IS CLASSIFIED "CLOSED--ACCEPTABLE ACTION/SUPERSEDED".

From: FAA
To: NTSB
Date: 12/10/1996
Response: THE FAA IS CONTINUING ITS EFFORTS TO SUPPLEMENT PROCEDURES FOR THE REDUNDANCY OF CRITICAL CONTROLLER TASKS. THESE EFFORTS INCLUDE THE AIRPORT SURFACE DETECTION EQUIPMENT (ASDE-3), THE AIRPORT MOVEMENT AREA SAFETY SYSTEM (AMASS), AND THE AIRPORT SURFACE TARGET IDENTIFICATION SYSTEM (ATIDS). THE ASDE-3 IS A SURFACE SURVEILLANCE RADAR SYSTEM DESIGNED TO DISPLAY AIRCRAFT AND VEHICLE TARGETS OPERATING ON AIRPORT MOVEMENT AREAS TO AIR TRAFFIC CONTROLLERS IN THE CONTROL TOWER. CURRENTLY, 23 ASDE-3 SYSTEMS HAVE BEEN COMMISSIONED. IT IS ANTICIPATED THAT THE REMAINING 17 SITES WILL BE COMMISSIONED BY 1999. THE FAA IS ALSO PLANNING TO DEPLOY 40 AMASS SYSTEMS--ONE FOR EACH ASDE-3 SYSTEM DEPLOYED TO ENHANCE THE EFFECTIVENESS OF THE ASDE-3. THE AMASS WILL PROVIDE CONTROLLERS WITH ACTIVE AUDIO AND VISUAL ALERTS ON POSSIBLE RUNWAY INCURSIONS. A PREPRODUCTION DEVELOPMENT SYSTEM WAS INSTALLED AT SAN FRANCISCO AND IS UNDERGOING OPERATIONAL AIR TRAFFIC CONTROL EVALUATION. THE FIRST AMASS SYSTEM IS EXPECTED TO BE COMMISSIONED IN 1998 AND THE FINAL SYSTEM IN 2000. THE ATIDS, A SAFETY COMPONENT OF THE AIRPORT SURFACE TRAFFIC AUTOMATION (ASTA) SYSTEM, IS A FURTHER ENHANCEMENT TO THE ASDE-3/AMASS. THE ATIDS IS NEEDED TO PROVIDE CONTROLLERS WITH THE CAPABILITY TO IDENTIFY AIRCRAFT AND VEHICLE TARGETS DISPLAYED ON THE ASDE-3/AMASS. THIS CAPABILITY WILL ALSO HELP MITIGATE MULTIPATH TARGET PROBLEMS (FALSE REFLECTIONS) COMMON IN THE ASDE-3 AND WILL LIKELY IMPROVE THE ACCURACY OF RUNWAY INCURSION ALERTS GENERATED BY THE AMASS. THE FAA ANTICIPATES FUNDING FOR ATIDS AND LOW-COST ALTERNATIVE SYSTEMS IN FISCAL YEAR 1999 WITH IMPLEMENTATION BETWEEN 2001 AND 2004. HOWEVER, WE REMAIN CONCERNED THAT WITHOUT FINANCIAL REFORM OF THE AGENCY, THESE INVESTMENTS WILL BE VERY DIFFICULT TO MAKE IN LIGHT OF CONSTRAINED RESOURCES. I WILL KEEP THE BOARD APPRISED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 7/11/1996
Response: AS YOU KNOW, ON 6/21/96, YOUR SENIOR STAFF BRIEFED ME AND SAFETY BOARD MEMBERS AND STAFF ON THE PROGRESS OF ASDE-3 PROGRAM, THE AMASS PROGRAM, AND OTHER RUNWAY INCURSION INITIATIVES BEING PURSUED BY THE FAA. WHILE WE WERE ENCOURAGED BY WHAT WE HEARD, AND NOTING THAT THE AMASS SYSTEM AT THE SAN FRANCISCO INTERNATIONAL AIRPORT BECAME OPERATIONAL ON 5/30/96, WE NONETHELESS REMAIN CONCERNED, AS A RESULT OF THIS BRIEFING, THAT THE AMASS PROGRAM AGAIN MAY EXPERIENCE UNANTICIPATED DELAYS. BECAUSE THE ASTA SYSTEM WILL BE AN ENHANCEMENT TO AMASS, THIS PROGRAM WOULD ALSO EXPERIENCE A DELAY. THE SAFETY BOARD VIEWS RUNWAY INCURSIONS AS A VERY SERIOUS SAFETY CONCERN AND URGES THE FAA TO MAINTAIN A STRONG FOCUS TOWARD A TIMELY COMPLETION OF THESE PROGRAMS WITH THE ULTIMATE GOAL OF COMMISSIONING ALL SYSTEMS. WE REQUEST THAT AN UPDATED TIMETABLE, WITH MILESTONES, FOR EACH OF THESE PROGRAMS BE PROVIDED IN THE FAA'S NEXT CORRESPONDENCE REGARDING THIS MATTER. PENDING FURTHER CORRESPONDENCE ON THIS IMPORTANT ISSUE, A-91-63 IS CLASSIFIED "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 3/21/1996
Response: AS PREVIOUSLY STATED, THE FAA IS DEVELOPING TWO SYSTEMS TO SUPPLEMENT CRITICAL CONTROLLER TASKS. THE FIRST SYSTEM WAS THE AIRPORT SURFACE DETECTION EQUIPMENT (ASDE-3) AND THE AIRPORT MOVEMENT AREA SAFETY SYSTEM (AMASS) ENHANCEMENT TO THE ASDE-3. THE FAA PLANS TO INSTALL A TOTAL OF 40 ASDE-3 SYSTEMS AT 35 AIRPORTS AND 2 SUPPORT SITES. AT THIS TIME, 20 HAVE BEEN COMMISSIONED WITH THE LAST SITE SCHEDULED FOR COMMISSIONING BY NOVEMBER 1999. THE FAA WILL INSTALL 40 AMASS SYSTEMS AT THE 35 AIRPORTS WHICH WILL HAVE AN ASDE-3. THE DEVELOPMENT SYSTEM THAT WAS DEMONSTRATED AND VALIDATED AT SAN FRANCISCO WAS FURTHER REFINED AND TESTED AT BOSTON AND ATLANTA. THE FAA DELIVERED THE LATEST PREPRODUCTION VERSION TO SAN FRANCISCO IN FEBRUARY 1996. THE SAN FRANCISCO SYSTEM WILL BEGIN OPERATIONAL AIR TRAFFIC CONTROLLER EVALUATIONS BY MAY 1996. THE FAA FINALIZED THE AMASS REQUIREMENTS IN APRIL 1995 AND NEGOTIATED CONTRACTOR PERFORMANCE CRITERIA DURING JULY AND AUGUST 1995. THE FAA IS PRESENTLY NEGOTIATING A CONTRACT FOR THREE FULL-SCALE DEVELOPMENT AMASS SYSTEMS. THE FIRST OF THESE SYSTEMS WILL BE INSTALLED IN FEBRUARY 1997 AND WILL BEGIN OPERATIONAL TESTING AND EVALUATION. ALL 40 AMASS SYSTEMS ARE SCHEDULED TO BE OPERATIONAL BY 2000. I WILL KEEP THE BOARD APPRISED OF THE FAA'S PROGRESS ON THIS RECOMMENDATION.

From: FAA
To: NTSB
Date: 6/5/1995
Response: ON 2/15/94, THE FAA TOLD THE BOARD THAT TWO SYSTEMS WERE BEING DEVELOPED TO SUPPLEMENT CRITICAL CONTROLLER TASKS. THE FIRST SYSTEM WAS THE AIRPORT SURFACE DETECTION EQUIPMENT (ASDE-3) AND THE AIRPORT MOVEMENT AREA SAFETY SYSTEM (AMASS) SOFTWARE ENHANCEMENT TO THE ASDE-3. ON 4/14/95, IN RESPONSE TO A-95-30 THROUGH -32, THE FAA PROVIDED INFORMATION TO THE BOARD ABOUT THE SCHEDULE TO COMMISSION ASDE-3. AT THAT TIME, 23 ASDE-3 SYSTEMS WERE DELIVERED AND 12 SITES WERE COMMISSIONED. THE 23 SYSTEMS THAT HAVE BEEN DELIVERED WILL BE COMMISSIONED BY SEPTEMBER 1995. THE FAA PLANS TO INSTALL A TOTAL OF 40 ASDE-3 SYSTEMS AT 35 AIRPORTS AND 2 SUPPORT SITES WITH THE LAST SITE SCHEDULED FOR COMMISSIONING BY NOVEMBER 1999. THE FAA WILL INSTALL 40 AMASS SYSTEMS AT THE 35 AIRPORTS WHICH WILL HAVE AN ASDE-3. FULL-SCALE DEVELOPMENT TESTING IS SCHEDULED TO BEGIN IN MAY 1996 AT SAN FRANCISCO, AND THE SYSTEMS ARE SCHEDULED TO BECOME OPERATIONAL BETWEEN 1997 AND 1999. THE LAST AMASS WILL BE OPERATIONAL IN DECEMBER 1999. THE SECOND SYSTEM IS THE AIRPORT SURFACE TRAFFIC AUTOMATION (ASTA) SYSTEM. FORTY ASTA SYSTEMS ARE PLANNED--ONE FOR EACH OF THE ASDE-3/AMASS INSTALLATIONS. THE ASTA SYSTEM WILL PROVIDE POSITIVE IDENTIFICATION AND DATA TAGS TO CONTROLLERS OF AIRCRAFT AND VEHICLES ON THE AIRPORT MOVEMENT AREA. THE FIRST ASTA IS SCHEDULED TO BE OPERATIONAL IN 2001 AND THE FINAL SYSTEM IN 2004. I WILL KEEP THE BOARD APPRISED OF THE FAA'S PROGRESS ON THIS SAFETY RECOMMENDATION.

From: NTSB
To: FAA
Date: 6/7/1994
Response: THE BOARD NOTES THAT THE FAA HAS DEVELOPED AN AIRPORT MOVEMENT AREA SAFETY SYSTEM (AMASS) TO PROVIDE CONTROLLERS WITH GRAPHIC, AURAL, & TEXT ALERTS ON POTENTIAL RUNWAY INCURSIONS. THE PROOF-OF-CONCEPT FOR THE AMASS COMMENCED ON MAY 10, 1993. THE FAA ANTICIPATES THAT THE FIRST OPERATIONAL AMASS INSTALLATION WILL BE COMMISSIONED IN JULY 1995, & THAT THE LAST OPERATIONAL SITE WILL BE COMPLETED IN NOVEMBER 1996. THE FAA ALSO INFORMED THE BOARD THAT THE RUNWAY INCURSION DEVICE PROGRAM HAS BEEN REASSESSED DUE TO PLANNED ENHANCEMENTS TO THE ASDE-3 SYSTEM. THE BOARD WOULD LIKE TO BE KEPT INFORMED OF ANY SIGNIFICANT DEVELOPMENTS IN THESE AREAS. BASED ON THIS INFO, THE BOARD CLASSIFIES A-91-063 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 2/15/1994
Response: THE FAA DEVELOPED ONE SYSTEM THE AIRPORT SURFACE DETECTION EQUIPMENT (ASDE-2) WHICH CURRENTLY IS UTILIZED BY 13 AIRPORTS. THE FAA HAS BEGUN TO IMPLEMENT A REPLACEMENT RADAR SYSTEM, THE ASDE-3 WHICH WILL PROVIDE SIGNIFICANTLY IMPROVED DETECTION CAPABILITY DURING HEAVY PRECIPITATION & WILL ADDITIONALLY ENHANCE THE TARGET DISPLAYS. THIS RADAR HAS BEEN DEPLOYED AT FOURTEEN SITES, WITH PLANS TO IMPLEMENTS IT AT ALL ASDE-2 SITES, AS WELL AS 22 OTHER AIRPORT LOCATIONS. IN ORDER TO MEET THE NEED FOR A LONG TERM SOLUTION TO THE RUNWAY PROBLEM, THE FAA IS ALSO DEVELOPING AN AIRPORT MOVEMENT AREA SAFETY SYSTEM (AMASS) THAT WILL PROVIDE CONTROLLERS WITH GRAPHIC, AURAL & TEXT ALERTS ON POTENTIAL RUNWAY INCURSIONS. THE PROOF-OF CONCEPT FOR THE AMASS COMMENCED ON MAY 10, 1993. THE FAA ANTICIPATES THE FIRST OPERATIONAL SITE WILL BE COMMISSIONED IN JULY, 1995 & THE LAST OPERATIONAL SITE IN NOVEMBER, 1996.

From: NTSB
To: FAA
Date: 3/27/1992
Response: THE SAFETY BOARD NOTES THAT THE FAA IS TAKING ACTION IN RESPONSE TO A-91-54 THROUGH -63 AND A-91-65 THROUGH -66 AND WILL KEEP US ADVISED OF PROGRESS. PENDING OUR FURTHER EVALUATION OF THESE RECOMMENDATIONS, THEY ARE CLASSIFIED AS "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 10/3/1991
Response: THE FAA IS DEVELOPING AND INSTALLING HARDWARE SYSTEMS TO SUPPLEMENT CRITICAL CONTROLLER TASKS. THE RUNWAY INCURSION DEVICE IS A VISUAL AND AURAL REMINDER TO THE CONTROLLER THAT A VEHICLE IS ON AN ACTIVE RUNWAY. THIS DEVICE HAS BEEN INSTALLED AT ALL CONTROL TOWERS THROUGHOUT THE NORTHWEST MOUNTAIN AND CENTRAL REGIONS. IT IS ANTICIPATED THAT THIS DEVICE WILL BE INSTALLED AT ALL LEVEL I, II, AND III CONTROL TOWERS BY THE SUMMER OF 1992. THE AIRPORT SURFACE DETECTION EQUIPMENT (ASDE-2) GROUND RADAR SYSTEM IS UTILIZED BY 13 FAA FACILITIES. THE ASDE-3 REPLACEMENT RADAR SYSTEM WILL DETECT TARGETS IN PERIODS OF HEAVY PRECIPITATION WHEN TARGET DETECTION IS MOST NECESSARY. THE ASDE-3 SYSTEM IS PRESENTLY BEING DEPLOYED AT ALL ASDE-2 SITES AND AT 16 OTHER BUSY AIRPORTS.