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Safety Recommendation Details

Safety Recommendation A-94-208
Details
Synopsis: ON JULY 2, 1994, ABOUT 1843 EASTERN DAYLIGHT TIME, AS DOUGLAS DC-9-31, N9554VJ, OPERATED BY USAIR, IN., AS FLIGHT 1016,CRASHED WHILE EXECUTING A MISSED APPROACH FOLLOWING AN INSTRUMENT LANDING SYSTEM APPROACH TO RUNWAY 18R AT CHARLOTTE/DOUGLAS INTERNATIONAL AIRPORT, CHARLOTTE, NORTH CAROLINA. THE CAPTAIN AND ONE FLIGHT ATTENDANT RECEIVED MINOR INJURIES; THE FIRST OFFICER, TWO FLIGHT ATTENDANTS, AND 18 PASSENGERS SUSTAINED SERIOUS INJURES; AND 37 PASSENGERS RECEIVED FATAL INJURIES. THE AIRPLANE WAS DESTROYED BY IMPACT FORCES AND A POSTCRASH FIRE. INSTRUMENT METEOROLOGICAL CONDITIONS PREVAILED, AND AN INSTRUMENT FLIGHT RULES FLIGHT PLAN HAD BEEN FILED. FLIGHT 1016 WAS BEING CONDUCTED UNDER THE PROVISIONS OF TITLE 14 CODE OF FEDERAL REGULATIONS (CFR) PART 121 AS A DOMESTIC, SCHEDULED PASSENGER SERVICE FLIGHT FROM COLUMBIA, SOUTH CAROLINA, TO CHARLOTTE.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ISSUED A FLIGHT STANDARDS INFORMATION BULLETIN TO OPERATORS OF AIRCRAFT EQUIPPED WIH A HONEYWELL STANDARD WINDSHEAR SYSTEM TO ASSURE THAT FLIGHT CREWMEMBERS OF THOSE AIRPLANES ARE ADVISED OF THE CURRENT LIMITATION OF THE SYSTEM THAT DELAYS WINDSHEAR WARNINGS TO FLIGHT CREWMEMBERS WHEN THE FLAPS ARE IN TRANSITION. (URGENT)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: CHARLOTTE, NC, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA94MA065
Accident Reports: Flight into Terrain during Missed Approach USAir 1016, DC-9-31, N954VJ
Report #: AAR-95-03
Accident Date: 7/2/1994
Issue Date: 11/28/1994
Date Closed: 11/14/1995
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 11/14/1995
Response: THE BOARD NOTES THAT THE FAA ISSUED BOTH AN AIRWORTHINESS DIRECTIVE & AN FSIB THAT ADDRESS NOTIFYING FLIGHTCREW OF THE POTENTIAL FOR DELAYED WARNINGS WITH THE HONEYWELL STANDARD WINDSHEAR SYSTEM. BECAUSE THIS ACTION SATISFIES THE INTENT OF THE RECOMMENDATION, THE BOARD CLASSIFIES A-94-208 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 9/5/1995
Response: ON 2/21/95, THE FAA PUBLISHED AIRWORTHINESS DIRECTIVE 95-04-01 TO ADDRESS THE PROBLEMS WITH THE HONEYWELL WINDSHEAR DETECTION & RECOVERY GUIDANCE SYSTEM ON CERTAIN BOEING & MCDONNELL DOUGLAS SERIES AIRPLANES. THIS AD REQUIRES THAT THE AIRPLANE FLIGHT MANUAL FOR THE APPLICABLE AIRPLANES BE REVISED TO INCLUDE A STATEMENT THAT, DURING SUSTAINED BANKS OF GREATER THAN 15 DEGREES OR DURING FLAP CONFIGURATION CHANGES, THE HONEYWELL WINDSHEAR DETECTION & RECOVERY GUIDANCE SYSTEM IS DESENSITIZED & ALERTS RESULTING FROM ENOUNTERING WINDSHEAR CONDITIONS WILL BE DELAYED. THIS AD WAS ISSUED TO ENSURE THAT THE FLIGHTCREWS ARE AWARE THAT THERE MAY BE SIGNIFICANT DELAYS IN THE HONEYWELL WINDSHEAR DETECTION & RECOVERY GUIDANCE SYSTEM IN DETCTING WINDSHEAR WHEN THE FLAPS OF THE AIRPLANES ARE IN TRANSITION. ON 7/18/95, THE FAA ISSUED FLIGHT STANDARDS INFO BULLETIN FOR AIR TRANSPORTATION 95-19, FLIGHT CREW ALERT: UNSAFE CONDITION IN WINDSHEAR FOR AIRCRAFT EQUIPPED WITH THE HONEYWELL STANDARD WINDSHEAR DETECTION & RECOVERY GUIDANCE SYSTEM. THIS BULLETIN DIRECTS PRINCIPAL OPERATIONS INSPECTORS TO ENSURE THAT THEIR OPERATORS ESTABLISH AN ACCEPTABLE MEANS OF INFORMING EACH FLIGHT CREWMEMBER OF THE REVISION TO THE AIRPLANE FLIGHT MANUAL REQUIRED BY AD 95-04-01. I CONSIDER THE FAA'S ACTION TO BE COMPLETED ON THIS SAFETY RECOMMENDATION.

From: NTSB
To: FAA
Date: 3/27/1995
Response: THE BOARD NOTES THAT THE FAA PLANS TO ISSUE AN FSIB, AS RECOMMENDED, BY 3/31/95, & WILL PROVIDE THE BOARD WITH A COPY OF THE BULLETIN AS SOON AS IT IS ISSUED. PENDING RECEIPT OF THE FSIB, THE BOARD CLASSIFIED THIS RECOMMENDATION "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 2/13/1995
Response: THE FAA AGREE WITH THIS RECOMMENDATION & WILL ISSUE A FLIGHT STANDARDS INFO BULLETIN BY 3/31/95. I WILL PROVIDE THE BOARD WITH A COPY OF THE BULLETIN AS SOON AS IT IS ISSUED.