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Safety Recommendation Details

Safety Recommendation A-94-209
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: CONDUCT A REVIEW OF THE CERTIFICATION OF THE HONEYWELL STANDARD WINDSHEAR SYSTEM, WITH EMPHASIS ON PERFORMANCE WHILE THE FLAPS ARE IN TRANSITION, AND REQUIRE THAT THE SYSTEM BE MODIFIED TO ENSURE PROMPT WARNING ACTIVATION UNDER THOSE CIRCUMSTANCES.
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: 4/22/1996
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/22/1996
Response: THE BOARD NOTES THAT THE FAA ISSUED AIRWORTHINESS DIRECTIVE (AD) 96-02-06, EFFECTIVE 2/26/96, REQUIRING THAT CURRENTLY INSTALLED HONEYWELL STANDARD WINDSHEAR SYSTEM COMPUTERS BE REPLACED WITH MODIFIED COMPUTERS CONTAINING NEW SOFTWARE THAT ELIMINATES DELAYS IN DETECTING WINDSHEAR WHEN THE FLAPS OF THE AIRPLANE ARE IN TRANSITION. BECAUSE THIS ACTION SATISFIES THE INTENT OF THE RECOMMENDATION, THE BOARD CLASSIFIES A-94-209 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 3/20/1996
Response: THE FAA ISSUED AIRWORTHINESS DIRECTIVE (AD) 96-02-06, EFFECTIVE 2/26/96, REQUIRING THAT CURRENTLY INSTALLED HONEYWELL STANDARD WINDSHEAR SYSTEM COMPUTERS BE REPLACED WITH MODIFIED COMPUTERS CONTAINING NEW SOFTWARE THAT ELIMINATES DELAYS IN DETECTING WINDSHEAR WHEN THE FLAPS OF THE AIRPLANE ARE IN TRANSITION.

From: NTSB
To: FAA
Date: 8/29/1995
Response: THE BOARD NOTES THAT THE FAA HAS COMPLETED A REVIEW OF THE HONEYWELL STANDARD WINDSHEAR SYSTEM & CONCLUDED THAT A MODIFICATION IS REQUIRED TO ELIMINATE DELAYS IN HAZARDOUS WINDSHEAR DETECTION. THE FAA ISSUED A NOTICE OF PROPOSED RULEMAKING PROPOSING TO REQUIRE THE INSTALLATION OF MODIFIED SOFTWARE THAT ELIMINATES DELAYS IN WINDSHEAR DETECTION WHEN THE AIRPLANE FLAPS ARE IN TRANSITION. THE BOARD AGREES WITH THE ACTION PROPOSED BY THE NPRM & BELIEVES THAT IT FULLY COMPLIES WITH THE INTENT OF THE SAFETY RECOMMENDATION. UNTIL THE AD IS ADOPTED, THE BOARD CLASSIFIES A-94-209 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 7/21/1995
Response: THE FAA COMPLETED ITS PRELIMINARY REVIEW OF THE HONEYWELL STANDARD WINDSHEAR DETECTION SYSTEM & OTHER AIRBORNE WINDSHEAR SYSTEMS TO DETERMINE IF THESE SYSTEMS DELAY DETECTION OF WINDSHEAR DURING FLAP CONFIGURATION CHANGES. THE FAA CONCLUDED THAT A MODIFICATION IS REQUIRED TO ELIMINATE DELAYS IN HAZARDOUS WINDSHEAR DETECTION. CONSEQUENTLY, THE FAA ISSUED A NOTICE OF PROPOSED RULEMAKING PROPOSING TO REQUIRE THAT THE CURRENTLY INSTALLED LINE REPLACEABLE UNIT BE REPLACED WITH A MODIFIED LINE REPLACEABLE UNIT HAVING NEW SOFTWARE THAT ELIMINATES DELAYS IN THE WINDSHEAR DETECTION SYSTEM DETECTING WINDSHEAR WHEN THE FLAPS OF THE AIRPLANE ARE IN TRANSITION. IF ADOPTED, THIS ACTION SHOULD PREVENT SIGNIFICANT DELAYS IN WINDSHEAR DETECTION SYSTEMS DETECTING HAZARDOUS WINDSHEAR.

From: NTSB
To: FAA
Date: 3/27/1995
Response: THE BOARD NOTES THAT THE FAA AGREES WITH THE RECOMMENDATION & IS REVIEWING THE HONEYWELL STANDARD WINDSHEAR SYSTEM TO DETERMINE THE EFFECTS OF SYSTEM DELAYS DURING FLAP CONFIGURATION CHANGES. AS AN INTERIM MEASURE, THE BOARD IS PLEASED TO LEARN THAT THE FAA PLANS TO ISSUE AN AIRWORTHINESS DIRECTIVE TO REVISE AIRPLANE FLIGHT MANUALS WITH INFO ON THE CURRENT SYSTEM DELAY. IN ADDITION, THE BOARD NOTES THAT THE FAA IS REQUIRING A DESIGN CHANGE TO ENSURE PROMPT WINDSHEAR WARNING ACTIVATION DURING FLAP TRANSITION & PLANS TO ISSUE AN AD ADDRESSING THIS ISSUE. PENDING RECEIPT OF THE ADS, THE BOARD CLASSIFIES A-94-209 "OPEN--ACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 2/13/1995
Response: THE FAA AGREES WITH THIS RECOMMENDATION & IS REVIEWING THE HONEYWELL STANDARD WINDSHEAR DETECTION SYSTEM & OTHER AIRBORNE WINDSHEAR SYSTEMS TO DETERMINE IF THESE SYSTEMS DELAY DETECTION OF WINDSHEAR DURING FLAP CONFIGURATION CHANGES. THE REVIEW WILL FOCUS ON THE IMPLEMENTATION OF A FLAP RATE COMPENSATION DURING FLAP CONFIGURATION CHANGES.