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Safety Recommendation Details

Safety Recommendation A-95-048
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: In cooperation with the National Weather Service, re-evaluate the central weather service unit "program and develop procedures to enable meteorologists to disseminate info about rapidly developing hazardous weather conditions, such as thunderstorm and low altitude windshear, to FAA TRACONs and tower facilities immediately upon detection.
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: 4/6/2011
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Air Traffic Control, Communication, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/6/2011
Response: The FAA previously informed the NTSB that, together with the NWS, it had completed an assessment of the CWSU program that had identified a number of shortcomings and needed improvements, including the issues specified in these recommendations. The NWS and the FAA were planning to revise the CWSU program to address the issues identified by the assessment. The FAA’s current letter reveals that, although the revisions to CWSU are not yet complete, in July 2010 a short-term plan was implemented to ensure standardized, consistent, measurable, and continuous operations. We note that CWSUs operate 16 hours per day, 7 days per week, and that the NWS Weather Forecast Office provides support for the remaining 8 hours of each day. In addition, CWSUs now provide finer resolution forecast information for TRACONs. In view of the age of these recommendations (Safety Recommendation A-95-48 is 16 years old, and Safety Recommendation A-01-58 is 9 years old), the NTSB considered whether the actions taken to date meet our intent in issuing them. The FAA worked with the NWS to reevaluate the CWSU program, and procedures have been developed and implemented that enable meteorologists to disseminate information about rapidly developing hazardous weather conditions to TRACONs and tower facilities immediately upon detection. Therefore, although NWS and the FAA continue to make further improvements to the CWSU program, Safety Recommendation A-95-48 is classified CLOSED – ACCEPTABLE ACTION. Although CWSUs are not staffed 24 hours per day, 7 days per week as recommended, and may therefore be closed during periods of significant weather, the NTSB believes that the NWS Weather Forecast Office providing support for periods when the CWSU is not open constitutes an acceptable alternate response; consequently, Safety Recommendation A-01-58 is classified “Closed—Acceptable Alternate Action.”

From: FAA
To: NTSB
Date: 2/7/2011
Response: CC# 201100065: - From J. Randolph Babbitt, Administrator: For several years, both the Federal Aviation Administration and the National Weather Service (NWS) have been researching other business models for improved CWSU weather support. This is an effort to continue to disseminate inforn1ation about rapidly developing hazardous weather conditions to FAA facilities in1n1ediately upon detection. Improved support includes: • Standardized, consistent, measurable and continuous operations. Outside of the support from the CWSUs 16 hours per day, 7 days per week schedule, the local weather forecast office will provide support for the remaining 8 hours of the day; and • Finer resolution forecast information for the terminal radar approach control (TRACON) domain. The agencies assen1bled a joint team of subject matter experts who worked together from September to Decen1ber 2009. The tean1 developed details to obtain these improvements using a 2-weather center model for remote weather support to the continental United States 20 Air Route Traffic Control Centers (ARTCC). The joint team developed the details for improvement in December 2009 as scheduled, which included a three-year transition and the transition includes a nine-month demonstration phase. In March 2010 rather than providing an updated plan with details proposed by the joint team, the NWS provided an alternative plan that continues the current CWSU configuration. The FAA was not prepared to accept the NWS alternative plan. In response, the FAA implen1ented a short-term plan on July 8, 2010, which enables meteorologists to disseminate information about hazardous weather conditions upon detection. This plan also maintains the current CWSU configuration, provides 24/7 support to the ARTCCs when CWSUs are closed via the NWS Weather Forecast Office, and provides a standard TRACON forecast from the CWSU for the ten busiest TRACONs. Additionally, the September 2009 Government Accountability Office report on restructuring of the CWSU program provided several recommendations with which both agencies concurred. A new agency joint team, comprised of NWS and FAA members, was formed. This joint team allows for a clear understanding on how the NWS can forecast the information required by the FAA and in turn develop firm requirements for near-term services to the Next Generation Air Transportation System Midterm Operating Capability (MOC) starting in 2015. The NWS is responsible for baselining current services in terms of what they are, their quantitative performance, and the costs of production. The joint-agency team will work together to refine performance requirements that could be implemented as early as October 2011 and will carry through until MOC. I will keep the Board informed of the FAA's progress on this safety recommendation.

From: NTSB
To: FAA
Date: 9/13/2005
Response: The Safety Board notes that the FAA has completed an assessment of the current operations of the CWSU and has published the results of its assessment. This assessment identified a number of shortcomings and needed improvements to the CWSU program, including the issues described in these recommendations. The NWS and the FAA are now working collaboratively to bring about major changes, proposed by the NWS, in the current operations of the CWSUs. The FAA is reviewing a proposal for restructuring and consolidating the CWSUs and, together with the NWS, is preparing budget, planning, and implementation documents to bring about these changes. The FAA believes that the transformation of the CWSU system should be completed about 2 years after initiation of the restructuring effort. The Safety Board believes that the review of the CWSU program by the FAA and the NWS has identified many significant improvements, and the Board is pleased by the FAA's plan to implement these improvements. Pending implementation of the revised CWSU program, Safety Recommendations A-95-48 and A-01-58 remain classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/20/2005
Response: Letter Mail Controlled 6/1/2005 8:03:19 AM MC# 2050231 - From Marion C. Blakey, Administrator: The Federal Aviation Administration made a commitment to install Automated Surface Observing System-Information Display System (ACE-IDS) in towers and Terminal Radar Approach Control (TRACON) facilities for the rapid dissemination of information on hazardous weather. Therefore, the remaining element of this safety recommendation is to reevaluate the Center Weather Service Units (CWSU) program, and to standardize the CWSU operations on a national basis. The FAA completed its assessment of the current operations of the CWSU and has published the results of its assessment. I have enclosed a copy of the report for the Board's information. The assessment concluded that the mission of the CWSU was uncertain and was not reflected in current operations. The opportunity to provide modern weather services by the CWSUs was not being met. The intramural responsibility of the CWSUs for the distribution of weather information had not been fulfilled and to some extent had been overtaken by technology. Extramural collaboration did not usually occur. The training function had been misdirected or disabled. The level of services provided by the CWSU was uneven and sharply deficient. Thus, the value of the CWSU products and services were marginal and met only the lowest standard for meteorological support. The National Weather Service (NWS) has agreed to restructure the CWSUs based on the constraints and opportunities expressed in the FAA's "Guidelines for Restructuring of the CWSUs." I have enclosed a copy of the guidelines for the Board's information. The NWS has proposed major changes in the operation of the CWSUs in a report entitled "An Integrated Concept for Enhancing Weather Support to the NAS," which is also enclosed for the Board's information. The NWS and the FAA are now working collaboratively to bring about these changes in the current operations of the CWSUs. In particular, we have agreed on the following new mission: …to be cognizant of hazardous weather information covering all phases of flight, participate in strategic planning, and support the transition to tactical operations. The scope of this mission is defined by the needs of the national system of traffic management that meets objectives of safety, efficiency, and security. The FAA is reviewing a proposal for restructuring and consolidating the CWSUs. This restructuring would give continuous service over the entire continental United States and utilize the opportunities available in remote video web conferencing. Several new products have been proposed: (1) hourly Hub Forecasts at 35 major terminals; (2) TRACON forecasts and TRACON Advisories to improve the current Center Weather Advisory; and (3) an Interactive Weather Briefing. These new products and services would be available to all air route traffic control centers, TRACONs, and to most airport traffic control towers. Most of all, the restructuring proposal would directly address three critical issues that were identified in the assessment report--training, program management, and financial controls. These provisions will require an investment that would transform the current CWSUs into a more effective delivery point for aviation weather that conforms to national standards and maintains continuous surveillance of weather hazards. The FAA is evaluating an investment analysis of this proposal. Two documents are in draft--Mission and Concept of Operations and a Project Management Plan. Subsequently, the FAA expects the NWS to respond with an Implementation Plan that would complete the transformation of the CWSUs in about 2 years after initiation of the restructuring effort. During this period of uncertainty and planning, the Interagency Agreement has been extended until September 30, 2005. A new Interagency Agreement is under consideration, pending decisions by the FAA and NWS. Although it was anticipated that these efforts would be concluded in 2003, the significant accomplishments noted above have contributed substantially to the FAA reconsidering the design for delivering weather services. Changes in these concepts will be reflected in revised FAA orders, if needed. I will keep the Board informed of the FAA's progress on these efforts.

From: NTSB
To: FAA
Date: 2/23/2004
Response: The Safety Board notes that the FAA transferred the CWSU program to the Air Traffic Tactical Operations organization in January 2003. The FAA reports that since then, several actions have been initiated to resolve the issues identified in these safety recommendations. The FAA stated that these actions included a joint FAA/NWS review of the present program and development of guidelines for restructuring the program. The FAA stated that it also inventoried present CWSU facilities, initiated a functional audit of the current network of centers, and solicited input from center managers. The Safety Board appreciates the FAA's recent efforts to resolve the CWSU staffing and communication issues. The Board requests copies of (1) the guidelines written for restructuring the CWSU program and (2) the interim interagency agreement between the FAA and NWS for review. Pending completion of a revised mission and restructuring plan and development of a new FAA Order 7210.38, "Center Weather Service Unit," that addresses the intent of these two recommendations, Safety Recommendation A-95-48 is classified "Open--Acceptable Response" and A-01-58 remains classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/21/2003
Response: Letter Mail Controlled 12/2/2003 8:41:43 AM MC# 2030585 - From Marion C. Blakey, Administrator: The CWSU program were transferred to the Air Traffic Tactical Operations organization in January 2003. Several efforts to meet this recommendation were described: · FAA and NWS reviewed the present program · FAA and NWS wrote guidelines for restructuring the CWSU program. · A functional audit of the current center network was initiated. · NWS initiated a "vision team" for future configurations. · FAA conducted an inventory of CWSU facilities. · FAA solicited input from center mamangers. The FAA reported that for the transition period a new Interagency Agreement has been prepared. The restructuring plan for the CWSUs will be presented to the FAA and NWS in Dec 2003.

From: NTSB
To: FAA
Date: 11/1/2002
Response: The Safety Board expressed concern in its letter of October 22, 2001, about the length of time that has passed since this recommendation was issued, but stated it was gratified that the FAA appeared to be in the final stages of completing the actions recommended. With the delay in implementing ACE-IDS, the continued failure to provide updated guidance and standardized procedures for CWSU operations becomes more critical. The Safety Board is concerned that Order 7210.38A has not yet been updated. The FAA first reported that in 1998 a draft had been given to the NWS. In 2000, the FAA reported that at a joint national conference with the NWS in February of that year, the participants agreed there was a need to review, update, and standardize CWSU duties. In 2001, the FAA reported that the FAA and NWS were revising the CWSU order and that it would be completed in early 2002. The FAA now reports it is waiting on the NWS to revise its operations manual before the CWSU order can be revised, and no time frame is given for completion. In responses to the related Safety Recommendation A-95-52, the NWS has consistently indicated to the Safety Board that it considers the FAA to be the lead agency in the concept of operations for CWSUs. In its most recent correspondence of October 19, 2001, the NWS reported that- The current (loosely defined) CWSU concept of operations does not contain language to indicate CWSU forecasters are responsible for monitoring and disseminating hazardous weather information to the various terminals within the Air Route Traffic Control Center area of responsibility, especially not to the level envisioned in recommendation A-95-52. Presently the CWSU weather forecaster's primary mission is to support en route air traffic operations. The NWS does intend to work with the FAA on updating the FAA's CWSU concept of operations, with a completion date of early 2002. The updated concept of operations will include complete review of forecaster duties and responsibilities. The Safety Board's specific concern is that FAA Order 7210.38A, out of date at the time of the accident in 1994, is still in effect 8 years later. The NWS has reported the same lack of currency for the CWSU order. In October 2001, Safety Recommendation A-95-48 was classified "Open--Acceptable Response" pending full deployment of ACE-IDS before the winter of 2001 and revision of FAA Order 7210.38A before the summer of 2002. Neither of those goals has been met. ACE-IDS deployment is now projected for completion in 2003, and the FAA has provided no projected date for revising the Order. The Safety Board urges the FAA to expedite its coordination with the NWS to complete the needed updates to their combined procedures. Pending issuance of revisions to Order 7210.38A, Safety Recommendation A-95-48 is classified OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 7/23/2002
Response: Letter Mail Controlled 07/25/2002 10:31:05 AM MC# 2020714 - From Jane F. Garvey, Administrator: The Federal Aviation Administration (FAA) is continuing to install an automated surface observing system. Controller Equipment-Information Display System (ACE-IDS) in eight terminal radar approach control (TRACON) facilities and other terminal facilities associated with TRACONs. The ACE-IDS will display numerous automated surface observing system outputs, as well as hazardous weather warnings and advisories, to the TRACON and tower controller. Four sites (Atlanta, Oklahoma City, Dallas/Fort Worth, and Reagan National) are commissioned and operational. Systems have been installed at Gateway, Potomac, Northern California, and Honolulu TRACONs. It was anticipated that installation at all sites would be completed by fall 2001. However, as a result of budget restraints, it is now anticipated that installation at the remaining four sites will be completed by fall 2003. The revision to Order 7210.38A, Center Weather Service Unit (CWSU), to standardize the CWSU operations on a national basis is contingent on the National Weather Service (NWS) completing a revision to its Operations Manual, Part D, Chapter 25, Support to Air Traffic Facilities. Once the NWS completes its revision, the FAA will incorporate the information into FAA Order 7210.38A.

From: NTSB
To: FAA
Date: 10/22/2001
Response: Although the Safety Board remains concerned about the length of time that has passed since this recommendation was issued, the FAA appears to be in the final stages of completing the actions recommended. Pending full deployment of ACE-IDS before the winter of 2001 and issuance of revisions to Order 7210.38A before the summer of 2002, Safety Recommendation A-95-48 remains classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/21/2001
Response: Letter Mail Controlled 08/29/2001 12:49:39 PM MC# 2010691 - From Jane F. Garvey, Administrator: The FAA is continuing to install an automated surface observing system Controller Equipment-Information Display System (ACE-IDS) in eight terminal radar approach control (TRACON) facilities and other terminal facilities associated with TRACONs. The ACE-IDS will display numerous automated surface observing system outputs, as well as hazardous weather warnings and advisories, to the TRACON and tower controller. Two sites (Atlanta and Oklahoma City) are commissioned and operational. It is anticipated that installation at remaining sites will be completed by fall 2001. Completion of installation is contingent on the availability of funding for this project. The FAA and the National Weather Service are revising Order 7210.38A, Center Weather Service Unit (CWSU), to standardize, on a national basis, the Center Weather Service Unit operations. It is anticipated that the order will be revised in early 2002. I will keep the Board informed of the FAA's progress on this safety recommendation.

From: NTSB
To: FAA
Date: 7/14/2000
Response: While the actions taken by the FAA meet the intent of this recommendation, the Board is disappointed that this work is not scheduled to be completed until the end of fiscal year 2001. This scheduled completion date is 6 1/2 years after this recommendation was issued. Although it has taken longer than the Safety Board believes was necessary, the FAA is currently taking the actions recommended. Pending full deployment of the ACE-IDS by the end of fiscal year 2001 and review of the FAA's final actions and changes to the CWSU program, A-95-48 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 6/5/2000
Response: Letter Mail Controlled 06/08/2000 2:59:26 PM MC# 2000737 - From Jane F. Garvey, Administrator: The National Weather Service (NWS) held a meeting the week of 2/7/00, with most of the center weather service unit (CWSU) meteorologists-in-charge and representatives from the FAA and NWS headquarters and regional offices to review current CWSU products and procedures. The participants at the meeting agreed on the need to review and update all documentation on CWSU duties. It was determined that there is a need to standardize, to the extent practicable, procedures and products. It was also determined that there should be equipment installed in the towers and terminal radar approach control (TRACON) facilities to enable the FAA to get all weather information to controllers, including hazardous weather, without the need for manual intervention. Consequently, the FAA is installing an automated surface observing system controller. Equipment-information display system (ACE-IDS) in eight TRACON facilities and other facilities associated with TRACONs. An example of a planned system is the one in the northern California TRACON, which will be connected to two other TRACONs, 19 airport traffic control towers, and two automated flight service stations. The ACE-IDS is designed to consolidate all weather and aeronautical information required by controllers into one display. The program schedule calls for the last system to be installed by the end of fiscal year 2001 if funding is available. I will keep the board informed of the FAA's progress on this safety recommendation.

From: NTSB
To: FAA
Date: 2/16/2000
Response: Pending review of the FAA's final actions and changes to the CWSU program, A-95-48 remains classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 12/13/1999
Response: Letter Mail Controlled 12/17/1999 2:19:56 PM MC# 991490 - From Jane F. Garvey, Administrator: The FAA has installed the weather and radar processor in each center weather service unit (CWSU) to improve information flow to the meteorologists. In February 2000, the FAA and the National Weather Service (NWS) will conduct a national conference to develop and document procedures for consistent execution of the duties of the meteorologists. Representatives from the FAA, the NWS, and the CWSU will participate in the conference. I will keep the Board informed of the FAA's progress on this recommendation.

From: NTSB
To: FAA
Date: 11/12/1998
Response: A-95-048 asked the FAA, in cooperation with NWS, to reevaluate the center weather service unit (CWSU) program and develop procedures to enable meteorologists to disseminate info about rapidly developing hazardous weather conditions, such as thunderstorms and low altitude windshear, to FAA terminal radar approach control and tower facilities immediately upon detection. Pending the publication and Board review of the revised CWSU Order, A-95-48 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/17/1998
Response: Letter Mail Controlled 9/21/98 3:39:40 PM MC# 981165 - From Jane F. Garvey, Administrator: The FAA is continuing its effort to standardize center weather service unit (CWSU) operations. The FAA has provided the NWS with a draft version of its needs. The news response to the FAA's draft will determine what changes need to be made to the national CWSU order.

From: NTSB
To: FAA
Date: 5/29/1998
Response: The Board notes that meteorologists will continue to staff the CWSU at the ARTCCs. With respect to the second issue, we appreciate your recognition of the need to standardize, on a national basis, the CWSU operations. Your decision to work with the NWS by rewriting the national CWSU order, based on the air traffic requirements, will go far toward enhancing the safety of the system. We look forward to working with you on this subject, A-95-48 remains classified OPEN – ACCEPTABLE RESPONSE, pending further action by the FAA.

From: FAA
To: NTSB
Date: 2/27/1998
Response: Letter Mail Controlled 3/5/98 3:58:40 PM MC# 980292 - From Jane F. Garvey, Administrator: The FAA has responded with info that they have stopped the testing of using ATC as weather info people, and will work with the NWS to develop standard formats throughout the nation for air traffic weather requirements.

From: NTSB
To: FAA
Date: 6/9/1997
Response: The FAA has expressed its concern that the Board classified the FAA's initial response to this recommendation "Open--Unacceptable Response" in the Board letter of 7/26/96. The FAA has stated that this classification was based on additional concerns that were not clearly outlined in the Board's original recommendation. The Board does acknowledge the efforts by the FAA to reevaluate the CWSU program and the FAA's recognition that weather reporting technology and training are dynamic, and a continual review of CWSU procedures and directives essential to provide the maximum benefit to the aviation community. Although the Board believes that these efforts are responsive to the recommendation, the Board remains concerned about the effects on safety of the FAA's initiative to replace the meteorologists at the CWSUs with enhanced weather-trained FAA air traffic control personnel. Therefore, the Board will continue to closely monitor this initiative to assess the impact on the weather support provided to the air route traffic control centers and other FAA air traffic control facilities. Pending review of the FAA's final actions regarding identifying future goals and responsibilities of the CWSUs, identifying any deficiencies in the CWSU program, and instituting any necessary improvements in the CWSU program A-95-48 is classified OPEN – ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 1/6/1997
Response: MC# 970045: - From Linda Hall Daschle, Acting Administrator: The FAA has reviewed its position in response to this recommendation and continues to believe that current procedures and directives address the specific concern outlined in the original recommendation. It is also recognized by the FAA and NWS that weather reporting technology and training are dynamic, and a continual review of procedures and directives is essential to provide the maximum benefit to the aviation community. The FAA has and continues to engage in bilateral discussion with the NWS regarding the identification of air traffic aviation weather needs associated with the performance of CWSUs. The FAA currently has a program under development to explore the concept of utilizing enhanced weather trained FAA air traffic control personnel to perform all CWSU duties. The FAA believes that the integration of air traffic knowledge into the weather collection, interpretation, and dissemination process will provide improvements in the info flow when significant weather impacts the air traffic environment. The FAA believes that it has addressed all to the concerns outlined by the Board. However, if the Board decides to keep this recommendation in an open status, the FAA requests an analysis of what FAA actions will result in a closure on this recommendation.

From: NTSB
To: FAA
Date: 7/26/1996
Response: The Board notes that the FAA has reevaluated the existing procedures to disseminate info about rapidly developing hazardous weather conditions to various air traffic control facilities and believes the procedures are appropriate. The Board appreciates the FAA's review; however, the Board believes that additional procedures must be developed to efficiently use and disseminate info on hazardous weather conditions available from current and planned meteorological systems for the CWSU, such as weather service radar-88D Doppler weather data. In addition, the FAA, in conjunction with the NWS, must make a timely, detailed, and comprehensive effort to reevaluate the current CWSU program to include identifying future goals and responsibilities of the CWSUS, identifying any deficiencies in the program and instituting improvements as necessary. These aspects of the recommendation were not addressed in the FAA's letter. Pending further correspondence on the FAA's plans to reevaluate the CWSU program and the results of that effort, A-95-48 is OPEN – UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/14/1995
Response: The FAA has reevaluated the existing procedures to disseminate info about rapidly developing hazardous weather conditions to various air traffic control facilities and believes that the procedures are appropriate to address this safety issue. The Central Weather Service, which is normally co-located with the traffic management unit, is staffed by a National Weather Service meteorological info (SIGMET), the meteorologist gives it to the weather coordinators in the traffic management unit. The weather coordinator then relays the SIGMET or other significant weather info to all terminal facilities that do not receive the info via automated services and whose geographical area lies within a 150-mile radius of the phenomena.