Charlotte 1994, US Air

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Date: July 02, 1994
Location: Charlotte, North Carolina
Aircraft: McDonnell Douglas DC-9-30
Reg: N954VJ
Airline: USAir
Flight No: 1016
Fatalities: 57 : 37

 
This USAir DC-9 crashed into trees and a residence after a missed approach at Charlotte, North Carolina.  The crew failured to recognize a windshear situation in a timely manner was determined as the cause.

 

http://www.planecrashinfo.com/w19940702.htm

 

37 killed, 20 injured.

US Airways

 

7/2/1994   1/19/1996   CHARLOTTE, NC   DOUGLAS DC-9-31   N954VJ   Fatal(37)   SCHD Part 121: Air Carrier USAIR  

 

NTSB Identification: DCA94MA065 .
The docket is stored in the Docket Management System (DMS). Please contact Records Management Division
Scheduled 14 CFR Part 121: Air Carrier USAIR
Accident occurred Saturday, July 02, 1994 in CHARLOTTE, NC
Probable Cause Approval Date: 1/19/1996
Aircraft: DOUGLAS DC-9-31, registration: N954VJ
Injuries: 37 Fatal, 16 Serious, 4 Minor.

THE AIRPLANE COLLIDED WITH TREES AND A PRIVATE RESIDENCE SHORTLY AFTER THE FLIGHTCREW EXECUTED A MISSED APPROACH FROM THE RWY 18R ILS. FLIGHTCREW WAS NOT PROVIDED UPDATED WX INFO IN ATIS;WX REFLECTED THUNDERSTORM & RAINSHOWER. TERMINAL DOPPLER WX RADAR NOT INSTALLED AT ARPT AS SCHEDULED; WOULD HAVE PROVIDED CONTROLLERS WITH INFO ABOUT SEVERITY OF WX, AND INFO WOULD HAVE BEEN BENEFICIAL TO FLIGHTCREW. INADEQ ATC PROCEDURES, BREAKDOWN IN COMM IN TOWER, PREVENTED FLIGHTCREW FROM RECEIVING ADDITIONAL CRITICAL INFO ABOUT ADVERSE WX OVER ARPT & ALONG APPROACH PATH. FLIGHT ENCOUNTERED WINDSHEAR OF 61 KTS OVER A 15 SEC PERIOD. INADEQ COMPUTER SOFTWARE DESIGN IN THE AIRPLANE'S ON-BOARD WINDSHEAR DETECTION SYSTEM PREVENTED FLIGHTCREW FROM RECEIVING MORE TIMELY WINDSHEAR ALERT. 1ST OFFICER INITIALLY ROTATED TO PROPER 15 DEG NOSE-UP ATTITUDE DURING MISSED APPROACH. HOWEVER, THRUST WAS SET BELOW STANDARD GO-AROUND EPR LIMIT OF 1.93, PITCH ATTITUDE REDUCED TO 5 DEG NOSE DOWN BEFORE FLIGHTCREW RECOGNIZED DANGEROUS SITUATION. FAA'S POI, USAIR'S MANAGEMENT, WERE AWARE OF INCONSISTENCIES IN FLIGHTCREW ADHERENCE TO OPERATING PROCEDURES WITHIN THE AIRLINE; HOWEVER, CORRECTIVE ACTIONS HAD NOT RESOLVED THIS PROBLEM.

The National Transportation Safety Board determines the probable cause(s) of this accident as follows:

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)

 

http://www.ntsb.gov/ntsb/brief.asp?ev_id=20001206X01727&key=1


 
This account was taken from the Aircraft Owners and Pilots Association and includes the actual transcript involving the aircraft and the tower.  It can be found at: http://www.aopa.org/asf/asfarticles/sp9506.html

There was no large outbreak of strong thunderstorms in North Carolina as the DC-9 was approaching Charlotte/Douglas International Airport from the southwest. The crew discussed a shower sitting at the edge of the airport and expected a visual approach. Following is a transcript of the communications in the cockpit and with Charlotte Approach and Tower. Conversation not pertinent to the weather has been omitted. The first officer was the pilot flying.

US1016: Radio transmission from the flight
CAPT: Captain cockpit communication
FO: First officer cockpit communication
APPR: Charlotte Approach Control
TWR: Charlotte Tower

18:36:59 APPR: "Tell you what, USAir 1016, may get some rain just south of the field. Might be a little bit just coming off the north. Just expect the ILS now. Amend your altitude...maintain 3,000."
18:39:02 CAPT: "If we have to bail out.... (unreadable)"
18:39:06 CAPT: "It looks like we bail out to the right."
18:39:09 FO: "Amen."
18:39:09 CAPT: "Ten miles to the VOR which is off the end of the runway. 'Bout a mile off the end of the runway."
18:39:14 FO: "Yeah."
18:39:16 CAPT: "So I think we'll be all right."
18:39:20 CAPT: "Chance of shear."
(The dialog in italics occurred on the tower frequency before USAir 1016 switched over at 18:39:30.)
18:39:12 US806 (on the ground, waiting to depart from Charlotte): "And 806, looks like we've gotten a storm right on top of the field here."
18:39:16 TWR: "USAir 806, affirmative."
18:39:20 US806: "We'll just delay for a while."
18:39:44 TWR: "...Charlotte Tower, Runway 18 Right, cleared to land. Following an F[okker] 100 (an airliner about the same size as a DC-9) on short final. Previous arrival reported a smooth ride all the way down final."
18:39:49 US1016: "USAir 1016, I'd appreciate a pirep from the guy in front of us."
18:40:10 FO: "Yep, laying right there this side of the airport, isn't it?"
18:40:14 CAPT: "Well."
18:40:15 FO: "The edge of the rain is, I'd say."
18:40:15 CAPT: "Yeah."
18:40:42 TWR: "USAir 1016, company FK 100 just exited the runway, sir; he said smooth ride."
18:40:48 TWR: "USAir 916, wind is showing 100 at 19."
18:40:56 FO: "One hundred at 19, eh?"
18:40:59 TWR: "USAir 1016, wind now 110 at 21."
18:41:05 CAPT: "Stay heads up."
18:41:06 TWR: "Wind shear alert, northeast boundary winds 190 at 13."
18:41:18 TWR: "Carolina 5211, Charlotte Tower, runway 18R, cleared to land, wind 100 at 20. Wind shear alert, northeast boundary wind 190 at 17."
18:41:32 TWR: "USAir 806, you want to just sit tight for a minute, sir?"
18:41:35 US806: "Yes, sir, we'd like to just sit tight."
18:41:37 TWR: "USAir 797, company aircraft in front of you is going to sit and wait a while, sir. Do you want to go in front of him?"
18:41:43 US797: "No, no, it wouldn't sound like a good plan. We'll, uh, it didn't look like a whole lot to us on the radar taxiing out, so it shouldn't be, uh, shouldn't be too many minutes."
18:41:54 CAPT: "Here comes the wipers."
18:41:56 FO: "All right."
18:41:57.6 (sound similar to rain concurrent with sound similar to windshield wipers starts. The sound continues until impact)
18:41:58.9 FO: "There's, ooh, 10 knots right there."
18:42:06.4 CAPT: "OK, you're plus 20."
18.42.14.0 CAPT: "Take it around; go to the right."
18:42:16.1 US1016: "USAir 1016's on the go (the DC-9's altitude is approximately 200 feet agl)."
18:42:17.7 CAPT: "Max power."
18:42:18.5 FO: "Yeah, max power.... "
18:42:18.5 TWR: "USAir 1016, understand you're on the go sir, fly runway heading. Climb and maintain 3,000."
18:42:19.4 FO: "Flaps to 15 [degrees]."
18:42:20.8 (clicks similar to flap handle being moved)
18:42:22.0 CAPT: "Down, push it down."
18:42:25.5 US1016: "Up to three, we're takin' a right turn here."
18:42:27.9 TWR: "USAir 1016, understand you're turning right? (US1016's altitude begins decreasing below 350 feet agl)."
18:42:28.4 ("Whoop whoop terrain" sound begins and continues to first sound of impact)
18:42:28.5 CAPT?: " — power."
18:42:32.7 (vibrating sound similar to aircraft stick shaker begins)
18:42:35.6 (sound of impact)

The NTSB determined the probable cause to be the flight crew's decision to continue an approach into weather conducive to a microburst, the crew's failure to recognize a wind shear situation in a timely manner, its failure to establish and maintain the attitude and thrust necessary to escape the wind shear, and the lack of real-time adverse weather and wind shear hazard information dissemination from air traffic control.

Several aircraft on the ground delayed takeoff despite the pirep of a smooth ride from the Fokker 100. When the tower issued the wind shear alert at 18:41:18, it was probably time to abandon the approach. The crew was focused on landing, but the weather was changing rapidly as the runway visual range dropped to 500 feet in heavy rain. It was determined later that there was a microburst one mile east of the approach end of 18R, with maximum winds of 50 knots. The net wind change was calculated at 86 knots during the DC-9's missed approach.

The flight crew's coordination could have been better, and the investigation concluded that the flight could have survived this wind shear encounter if several factors had been different:

  • Maximum go-around power was not used. Approximately 2,000 more pounds of thrust were available. The first officer used the missed approach procedure instead of the wind shear recovery profile.
  • Missed approach calls for max normal power, a maximum 15-degree nose-up attitude, flaps retracted to 15 degrees, and gear up. The wind shear profile mandates full throttle, 15 degrees nose up initially followed by two-degree increases as needed to stick shaker, and the aircraft is left in its current configuration (gear and flaps down in this case).
  • The captain may have experienced vestibular illusion that gave him a false sense of the aircraft's being over-rotated to an abnormally steep pitch attitude. This is caused by the strong acceleration of the aircraft and must be overcome by reference to the flight instruments. The first officer, who was flying, was on the gauges and situationally focused. The captain was not, which led him to call for a reduction in pitch attitude.
  • The tower was cited for not reporting observed lightning to the aircraft and for failure to mention the rapidly diminishing visibility in heavy rain and other multiple low-level wind shear alerts.

 

 

 

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