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Aviation accident DCA94MA065

37 fatal · DOUGLAS DC-9-31 · 1994-07-02 · CHARLOTTE, NC, USA

Event

NTSB number
DCA94MA065
Event ID
20001206X01727
Type
Accident
Date
1994-07-02
Location
CHARLOTTE, NC, USA
Coordinates
35.230934, -80.910842

Injuries

Highest injury
FATL
Fatal
37
Serious
16
Minor
4
Uninjured
0
Total aboard
57

Aircraft

Make
DOUGLAS
Model
DC-9-31
Registration
N954VJ
FAR Part
121
Engines
2
Damage
DEST

Conditions

Light
DAYL
Weather
IMC

Probable cause

1) THE FLIGHTCREW'S DECISION TO CONTINUE AN APPROACH INTO SEVERE CONVECTIVE ACTIVITY THAT WAS CONDUCIVE TO A MICROBURST; 2) THE FLIGHTCREW'S FAILURE TO RECOGNIZE A WINDSHEAR SITUATION IN A TIMELY MANNER; 3)THE FLIGHTCREW'S FAILURE TO ESTABLISH AND MAINTAIN THE PROPER AIRPLANE ATTITUDE AND THRUST SETTING NECESSARY TO ESCAPE THE WINDSHEAR; AND 4) 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 THE 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: 1) THE LACK OF AIR TRAFFIC CONTROL PROCEDURES THAT WOULD HAVE REQUIRED THE CONTROLLER TO DISPLAY AND ISSUE AIRPORT SURVEILLANCE RADAR (ASR-9) WEATHER INFORMATION TO THE PILOTS OF FLIGHT 1016; 2) THE CHARLOTTE TOWER SUPERVISOR'S FAILURE TO PROPERLY ADVISE AND ENSURE THAT ALL CONTROLLERS WERE AWARE OF AND REPORTING THE REDUCTION IN VISIBILITY AND RUNWAY VISUAL RANGE VALUE INFORMATION, AND THE LOW LEVEL WINDSHEAR ALERTS THAT HAD OCCURRED IN MULTIPLE QUADRANTS; 3) THE INADEQUATE REMEDIAL ACTIONS BY USAIR TO ENSURE ADHERENCE TO STANDARD OPERATING PROCEDURES; AND 4) THE INADEQUATE SOFTWARE LOGIC IN THE AIRPLANE'S WINDSHEAR WARNING SYSTEM THAT DID NOT PROVIDE AN ALERT UPON ENTRY INTO THE WINDSHEAR. (NTSB REPORT AAR-95/03)

Source

Authoritative
NTSB CAROL
Machine
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