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Safety Recommendation Details

Safety Recommendation A-95-041
Details
Synopsis: On 7/2/94, about 1843 eastern daylight time, a Douglas DC-9-31, N954VJ, operated by USAIR, Inc., as flight 1016, collided with trees and a private residence near the Charlotte/ Douglas International Airport, Charlotte, North Carolina, shortly after the flightcrew executed a missed approach from the instrument landing system approach to runway 18R. The captain, first officer, one flight attendant, and one passenger received minor injuries. Two flight attendants and 14 passengers sustained serious injuries. The remaining 37 passengers received fatal injuries. The airplane was destroyed by impact forces and a postcrash fire. Instrument meteorological conditions prevailed at the time of the accident, and an instrument flight rules flight plan had been filed. Flight 1016 was being conducted under 14 code of federal regulations part 121 as a regularly scheduled passenger flight from Columbia, South Carolina, to Charlotte.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Amend FAA Order 7110.65, Air Traffic Control, chapter 2, General Control, section 6, Weather Info, paragraph 2-115, reporting weather conditions, to require the tower supervisor to notify tower and radar approach control facility personnel, in addition to the National Weather Service observer, of the deterioration of prevailing visibility to less than 3 miles. Additional, require the controllers to issue the visibility value to pilots until the info is broadcast on the ATIS and the pilots have acknowledged receipt of the info.
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: 5/16/1995
Date Closed: 6/9/1997
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Air Traffic Control, Procedures, Procedures: Air Traffic Control, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/9/1997
Response: THE FAA MAINTAINS, & THE BOARD ACKNOWLEDGES, THAT THE CURRENT PROCEDURE OUTLINED IN FAA ORDER 7110.65 REQUIRES THAT ATIS BOARDCASTS BE PROMPTLY UPDATED WHENEVER ANY CONDITIONS CONDUCIVE TO THUNDERSTORMS ARE OBSERVED. A-95-41 ASKED THE FAA TO AMEND FAA ORDER 7110.65, "AIR TRAFFIC CONTROL," CHAPTER 2, "GENERAL CONTROL," SECTION 6, "WEATHER INFO," PARAGRAPH 2-115, (NOW PARAGRAPH 2-6-6) "REPORTING WEATHER CONDITIONS," TO REQUIRE THE TOWER SUPERVISOR TO NOTIFY TOWER & RADAR APPROACH CONTROL FACILITY PERSONNEL, IN ADDITION TO THE NWS OBSERVER OF THE DETERIORATION OF PREVAILING VISIBILITY TO LESS THAN 3 MILES. THE RECOMMENDATION ALSO ASKED THE FAA TO REQUIRE THE CONTROLLERS TO ISSUE THE VISIBILITY VALUE TO PILOTS UNTIL THE INFO IS BROADCAST ON THE ATIS & THE PILOTS HAVE ACKNOWLEDGED RECEIPT OF THE INFO. THEREFORE, THE BOARD CLASSIFIES A-95-41 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 1/6/1997
Response: THE FAA AMENDED FAA ORDER 7210.3, FACILITY OPERATIONS & ADMINISTRATION, PARAGRAPH 2-7-2 RECEIPT & DISSEMINATION OF WEATHER OBSERVATIONS TO REQUIRE MANAGERS IMPLEMENT PROCEDURES TO ENSURE ALL OPERATING POSITIONS RECEIVE & ACKNOWLEDGE ANY VISIBILITY CHANGES WHEN THE TOWER IS RESPONSIBLE FOR REPORTING THE VISIBILITY.

From: NTSB
To: FAA
Date: 7/26/1996
Response: THE BOARD NOTES THAT THE FAA MAINTAINS THAT THE REQUIREMENTS IN THIS RECOMMENDATION ARE ALREADY CONTAINED IN AGENCY ORDERS. ORDER 7210.3, "FACILITY OPERATIONAL & ADMINISTRATION," PARAGRAPH 2-121, REQUIRES THAT AIR TRAFFIC MANAGERS ESTABLISH A PROCEDURE TO INFORM AIR TRAFFIC PERSONNEL OR WEATHER OBSERVATION AS SOON AS THEY ARE RECEIVED. ORDER 7110.65H, PARAGRAPH 2-141B, 2-141C, & 2-141D, CURRENTLY REQUIRE AIR TRAFFIC CONTROLLERS TO ISSUE THE VISIBILITY VALUE TO PILOTS UNTIL THE INFO IS BROADCAST ON THE ATIS & THE PILOTS ACKNOWLEDGE RECEIPT OF THE LATEST INFO. THE BOARD BELIEVES THAT A-95-41 REMAINS VALID. AS OUTLINED IN FAA ORDER 7110.65, "REPORTING WEATHER CONDITIONS," WHEN THE PREVAILING VISIBILITY DECREASES TO LESS THAN 4 MILES, TOWER PERSONNEL SHALL TAKE THE PREVAILING VISIBILITY OBSERVATIONS. THEY ARE PROVIDED WITH SPECIFIC DIRECTION ON HOW TO APPLY THE OBSERVATION. HOWEVER, DURING THOSE PERIODS WHEN TOWER PERSONNEL ARE RESPONSIBLE FOR THE DETERMINATION OF PREVAILING VISIBILITY. THERE IS NO GUIDANCE THAT DIRECTS THEM TO ENSURE THAT ALL AIR TRAFFIC OPERATIONAL POSITIONS WITHIN THE FACILITY, IN ADDITION TO THE WEATHER OBSERVER, RECEIVE THAT CURRENT OBSERVATION. BECAUSE THE TIMELY DISSEMINATION OF WEATHER & VISIBILITY IS CRITICAL DURING THE DYNAMIC ENVIRONMENT CREATED DURING THESE PERIOD, THE BOARD BELIEVES THAT SPECIFIC GUIDANCE TO THE AIR TRAFFIC CONTROL WORKFORCE SHOULD BE PROVIDED. UNLIKE FAA ORDER 7210.3, WHICH "PROVIDES INSTRUCTION, STANDARDS, & GUIDANCE FOR OPERATING & MANAGING AIR TRAFFIC FACILITIES," FAA ORDER 7110.65, " PRESCRIBES AIR TRAFFIC CONTROL PROCEDURES." THE MARKED DIFFERENCE IN THE PURPOSE OF EACH RESPECTIVE ORDER PROVIDES THE RATIONALE FOR URGING THE FAA TO AMEND ORDER 7110.65, WHICH IS SPECIFIC TO THE RESPONSIBILITIES OF CONTROLLERS. THE BOARD IS HOPEFUL THAT THIS EXPLANATION CLARIFIES ANY MISUNDERSTANDING ABOUT THE INTENT OF RECOMMENDATION & URGES THE FAA TO RECONSIDER ITS POSITION. PENDING FURTHER RESPONSE, A-95-41 IS CLASSIFIED "OPEN--UNACCEPTABLE RESPONSE."

From: FAA
To: NTSB
Date: 8/14/1995
Response: THE FAA REQUIREMENTS REFLECTED IN THIS RECOMMENDATION ARE ALREADY CONTAINED IN AGENCY ORDERS. ORDER 7210.3K, FACILITY OPERATION & ADMINISTRATION, PARAGRAPH 2-121, REQUIRES THAT AIR TRAFFIC MANAGERS ESTABLISH A PROCEDURE TO INFORM AIR TRAFFIC PERSONNEL OF WEATHER OBSERVATIONS AS SOON AS THEY ARE RECEIVED. THIS INCLUDES A CHANGE OF VISIBILITY TO LESS THAN 3 MILES (WHICH IS SIGNIFICANT BECAUSE THIS IS A DIVISION BETWEEN VISUAL & INSTRUMENT FLIGHT RULES). ORDER 7110.65H, PARAGRAPHS 2-141B, 2-141C & 2-141D, CURRENTLY REQUIRE AIR TRAFFIC CONTROLLERS TO ISSUE THE VISIBILITY VALUE TO PILOTS UNTIL THE INFO IS BROADCAST ON THE ATIS & THE PILOTS ACKNOWLEDGE RECEIPT OF THE LATEST INFO. I CONSIDER THE FAA'S ACTION TO BE COMPLETED, & I PLAN NO FURTHER ACTION ON THE RECOMMENDATION.