On July 2, 1994, 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.
We determined that the probable causes of the accident were:
- the flightcrew's decision to continue an approach into severe convective activity that was conducive to a microburst;
- the flightcrew's failure to recognize a windshear situation in a timely manncr.
- the flightcrew's failure to establish and maintain the proper airplane attitude and thrust setting necessary to escape the windshear; and
- the lack of real time adverse weather and windshear hazard information dissemination from air traffic control, all of which led to an encounter with and failure to escape from a microburst-induced windshear that was produced by a rapidly developing thunderstorm located at the approach end of runway 18R.
Contributing to the accident were:
- the lack of air traffic control procedures that would have required the controller to display and issue airport surveillance radar (ASR-9) weather infomation to the pilots of flight 1016:
- the Charlotte tower supervisor's failure to properly advise and ensure that all controllers were aware of and reporting the reduction in visibility and the runway visual range value information, and the low level windshear alerts that had occurred in multiple quadrants;
- the inadequate remedial actions by USAir to ensure adherence to standard operating procedures; and
- the inadequate software logic in the airplane's windshear warning systern that did not provide an alert upon entry into the windshear.
As a result of its investigation of this accident, we made the following recommendations:
To the Federal Aviation Administration:
- Amend FAA Order, 7110.65, Air Traffic Control, Chapter 2, General Control, Section 9, Automatic Terminal Information Service (ATIS} Procedures, paragraph 2-141, Operating Procedures, to ensure that broadcasts are promptly updated whenever any conditions conducive to thunderstorms are observed. These conditions would include, but not be limited to, windshear, lighting, and rain. Additionally, require that controllers issue these items until the information is broadcast on the ATIS and the pilots have acknowledged receipt of the information. (A-95-40)
- Amend FAA Order 7110.65. Air Traffic Control. Chapter 2, General Control, Section 6, Weather Information, 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. Additionally, require the controllers to issue the visibility value to pilots Wttil the infonnation is broadcast on the ATJS and the pilots have acknowledged receipt of the information. (A-95-41)
- Amend FAA Order 7110.65, Chapter 2. Section 6, paragraph 2-113, to require radar and tower controllers to display (including on BRITE) the highest levels of precipitation, whether it is VIP level 1 or level 6, as depicted by ASR-9 radar, and issue the information to flightcrews. (A-95-42)
- Provide clear guidance to all air traffic controllers and supervisors that "blanket broadcasts" in the tower cab without receiving acknowledgments are unacceptable methods of communicating information, and require that all advisories, coordination, and pertinent information disseminated to controllers are acknowledged by the individual controller to ensure receipt of the information. (A-95-43)
- Require that the FAA record the precipitation levels detected by the ASR-9 radar system, and retain the information for use in the reconstruction of events durng incident/accident investigations. (A-95-44)
- Develop and disseminate guidance and definitive standards to FAA inspectors to ensure a clearly identified system of checks and balances for FAA programs, such as compliance through partnership," and provide the necessary training to ensure the understanding of such programs. (A-95-45)
- Require that Principal Operations Inspectors (POIs) ensure that their respective air carrier(s) adhere to the company'" operating procedures, and emphasize rigorous compliance to checklist procedures. (A-95-46)
- Review all low level windshear alert system (LLW AS) installations to identify possible deficiencies in performance, similair to those identified by the sheltered wind sensors at the Charlotte/Douglas International Airport, and correct such deficiencies to ensure optimum performance of the LLWAS. (A-95-47)
- In cooperation with the National Weather Service. re-evaluate the Central Weather Service Unit (CWSU) program and develop procedures to enable meteorologists to disseminate information about rapidly developing hazardous weather conditions such as thunderstonns and low altitude windshear. to FAA TRACONs and tower facilities immediately upon detection. (A-95-48).
- Reevaluate the
Windshear Training Aid based on the facts, conditions, and circumstances of this accident, with the view toward incorporating additional simulator training cues, such as scenarios in which no turbulence is encountered, before the onset of the actual windshear, and to include procedures for using the windshear escape maneuver, in lieu of a missed approach procedure, when the airplane is in the final approach phase (below 1,000 feet) and conditions conducive to windshear are present, regardless of whether the pilot encounters airspeed fluttuations or precipitation. (A-95-49)
- Develop standards for forward-facing, integrated child safety seats for transport category aircraft. (A-95-50)
- Revise 14 Code of Federal Regulations Parts 91, 135, and 121 to require that all occupants be restrained during lakeoff, landing, and turbulent conditions, and that all infants and small children be restrained in a manner appropriate to their size. (A-95-51)
to the National Weather Service:
- Reevaluate, in cooperation with the FAA, the CWSU program, and develop procedures to enable meteorologists to disseminate information about rapidly developing hazardous weather conditions, such as thunderstorms and low altitude windshear, to FAA TRACONs and tower facilities in1mediately upon detection. (A-95-52)
- Conduct periodic check airmen training and flight check reviews to ensure standardization among check airmen with regard to complying with USAir's operating procedures. (A-95-53)
- Reemphasize the necessity for flightcrews to achieve and maintain diligence in the use of all applicable checklists and operatings procedures. (A-95-54)
- Reemphasize in pilot training and flight checking the cues available for identifying convective activity and recognizing associated microburst windshears; and provide additional guidance to pilots on operational (initiation and continuation of flight) decisions involving flight into terminal areas where convective activity is present. (A-95-55)
- Review company procedures regarding passenger counts on manifests to ensure their accuracy and accountability of all occupants on the airplane. (A-95-56)
