Safety Recommendation A-15-010
Details
Synopsis: The National Transportation Safety Board (NTSB) urges the Federal Aviation Administration (FAA) to take action on the safety recommendations issued in this letter. These recommendations address the issuance of landing clearances with multiple airports in the vicinity and minimum safe altitude warning (MSAW) software limitations. The recommendations are derived from our investigations of wrong airport landing events. As a result of these investigations, we have issued two safety recommendations, both of which are addressed to the FAA. Information supporting these recommendations is discussed below.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Modify the minimum safe altitude warning (MSAW) software to apply the MSAW parameters for the flight plan destination airport to touchdown, rather than automatically reassigning the flight to another airport based on an observed (and possibly incorrect) trajectory.
Original recommendation transmittal letter: PDF
Overall Status: Open Acceptable Alternate Response
Mode: Aviation
Location: Branson, MO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA14IA037
Accident Reports:
Report #: None
Accident Date: 1/12/2014
Issue Date: 5/4/2015
Date Closed:
Addressee(s) and Addressee Status: FAA (Open Acceptable Alternate Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 6/22/2020
Response: We note that you believe the procedural guidance contained in FAA Order JO 7110.65Y, paragraph 7-4-3, is sufficient, and you do not intend to amend the guidance; however, to reinforce this procedure, you created a briefing sheet and a training video that narrates a controller’s actions during an actual attempted wrong airport landing. We note that, in June 2019, you distributed the video and a mandatory face-to-face, “Wrong Airport Landing” briefing document to all FAA Air Traffic Organization operational personnel and management. We also note that you are in the process of enhancing the Standard Terminal Automation Replacement System (STARS), which will considerably reduce the possibility of wrong airport landings. As part of this enhancement, when an aircraft track is headed to the wrong airport, an aural alarm will sound, the color of the datablock will change, and the datablock will also display “WA” in line 0. We believe the training video and briefing document, along with the STARS enhancement (including implementation and training), will constitute an acceptable alternate solution to Safety Recommendation A-15-9. We also believe that the STARS enhancement, once completed, represents an acceptable alternate solution to Safety Recommendation A-15-10. Accordingly, pending completion of those actions, Safety Recommendation A-15-9 is classified “Open—Acceptable Alternate Response,” and Safety Recommendation A-15-10 remains classified OPEN--ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 2/18/2020
Response: -From Steve Dickson, Administrator: Originally, the NTSB recommended modifying the MSAW software to apply the MSA W parameters for the flight plan destination airpo11 to touchdown, rather than automatically reassigning the flight to another airport based on an observed (and possibly incorrect) trajectory. As previously stated, the FAA does not concur with this recommendation as written based on the fact that there is currently nothing in the design of the MSA W software to address the issue cited in the NTSB report. Instead, the FAA explored other possible automation enhancement solutions leading to the creation of site rule STARS-0-0116, which is available to the field as part of the set of STARS site rules. The functionality included in STARS-0-0116 is now being implemented in STARS software as part of the R l 0 software release. As stated above, with this functionality, when an aircraft track is headed to the wrong airport (i.e., intruding into a geographic area around the airport), STARS will: • Change the datablock color; • Display "WA'. in line 0 of the datablock; and • Sound an aural alarm. I believe the FAA has effectively addressed Safety Recommendation A-1 5-9 and consider our actions complete. I will keep the Board informed of the FAA's progress on Safety Recommendation A-15-10 and anticipate providing an update by May 2021.

From: NTSB
To: FAA
Date: 11/12/2015
Response: We note that, although you do not concur with this recommendation because “the current design of the MSAW tool does not contain any element to address” it, you plan to investigate other possible software solutions aside from MSAW that would satisfy Safety Recommendation A-15-10. We continue to believe that, despite this issue with the current MSAW system, a simple and effective revision to the system is to compare the destination airport in the flight plan that the MSAW is using to the adaptation that the MSAW is applying to the aircraft, and to note when they are different. Such a revision would alert controllers to a potential wrong-airport landing. Other possible software revisions that you identify and implement could also satisfy the recommendation. We request that you describe these alternatives in sufficient detail so that we may determine whether they fully address Safety Recommendation A-15-10. Pending your doing so, and your implementation of an acceptable alternative, Safety Recommendation A 15 10 is classified OPEN—ACCEPTABLE ALTERNATE RESPONSE.

From: FAA
To: NTSB
Date: 7/31/2015
Response: -From Michael P. Huerta, Administrator: The FAA does not concur with this safety recommendation as written. Both the MSAW Governance Committee Chairman and National Air Traffic Controllers Association representatives verified that the current design of the MSA W tool docs not contain any element to address this Safety Recommendation. However, we plan to investigate possible software solutions aside from MSA W such as flight plan conflict automation. If feasible, potential automation changes would have to be assessed for complexity cost and schedule. I will keep the Board informed of the progress of these recommendations and provide an update by September 2016.