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Safety Recommendation Details

Safety Recommendation A-81-041
Details
Synopsis: ON JANUARY 20, 1981, A BEECH B-99, N390CA, OPERATED BY CASCADE AIRWAYS, INC., AS FLIGHT 201, CRASHED ABOUT 4.5 MILES SOUTHWEST OF SPOKANE INTERNATIONAL AIRPORT, SPOKANE, WASHINGTON. THE ACCIDENT OCCURRED WHILE THE PILOT WAS ATTEMPTING A LOCALIZER APPROACH TO RUNWAY 3 (LOC RWY 3) AT SPOKANE INTERNATIONAL AIRPORT. THE TWO PILOTS AND FIVE PASSENGERS DIED IN THE ACCIDENT; TWO PASSENGERS SURVIVED WITH SERIOUS INJURIES. THE AIRCRAFT WAS DESTROYED BY THE IMPACT AND POSTCRASH FIRE.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: REVIEW ALL APROACH PROCEDURES AND IDENTIFY THOSE AIRPORTS THAT HAVE A LOCALIZER OR INSTRUMENT LANDING SYSTEM APPROACH WITH DISTANCE MEASURING EQUIPMENT FACILITIES AT TWO POINTS ALONG THE FINAL APPROACH COURSE, LEADING TO THE POSSIBILITY OF ERRONEOUS TUNING, AND ADD A PRECAUTIONARY NOTE ON THE PERTINENT APPROACH CHART.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
Mode: Aviation
Location: Spokane, WA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA81AA006
Accident Reports: Cascade Airways, Inc., Beechcraft 99A, N390CA
Report #: AAR-81-11
Accident Date: 1/20/1981
Issue Date: 3/30/1981
Date Closed: 3/29/1982
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/29/1982
Response: We are now informed that the FAA has reconsidered A-81-39 through -41 and has decided against their adoption. Since we do not agree with the FAA's decision, they are classified in a "Closed--Unacceptable Action" status.

From: FAA
To: NTSB
Date: 10/19/1981
Response: FAA LTR: THE FAA HAS RECONSIDERED THIS RECOMMENDATION, REEVALUATED THE SPOKANE LOCALIZER APPROACH TO RUNWAY 3 (LOC RWY 3) STANDARD INSTRUMENT APPROACH PROCEDURE, AND AGAIN REVIEWED TRANSCRIPTS OF TESTIMONY OBTAINED FROM THE APRIL NTSB HEARING IN SPOKANE. OUR ANALYSIS OF THESE DATA LEADS US TO CONCLUDE THAT OUR ORIGINAL RESPONSE OF JUNE 26, 1981, WAS APPROPRIATE IN EVERY RESPECT. THE FAA INTENDS TO TAKE NO FURTHER ACTION RELATIVE TO THIS RECOMMENDATION.

From: NTSB
To: FAA
Date: 9/2/1981
Response: We recognize that information developed in the investigation of the January 20, 1981 crash subsequent to the issuance of these safety recommendations essentially negated the involvement of the approach plates as a causal factor in the accident. Nevertheless, although the FAA's review has concluded otherwise, we continue to believe that the manner in which the Spokane LOC Rwy 3 approach is depicted on approach plates constitutes a potential hazard. During the course of the Board's Public Hearing in Spokane, several highly experienced pilots testified as to having Data Source: NTSB Recommendations to FAA and FAA Responses had difficulty understanding the LOC Rwy 3 approach procedure as depicted on the approach plate. Insofar as we can determine (testimony of the Chief of the Seattle FIFO), FAA does not utilize personnel who have expertise or formal training in the field of human engineering in reviewing capability to reasonably determine or evaluate the benefit to any but the more highly skilled pilot of adding or deleting a precautionary note relative to any instrument approach. We note with interest that the September 1977 edition of the Spokane LOC Rwy 3 approach plate depicted only one distance measuring equipment (DME) facility. Yet, a precautionary note was contained on the profile view alerting pilots to where the "only DME facility" on the approach plate was located. In the January 1981 edition, however, there were two DME facilities depicted on the LOC Rwy 3 approach plate. We find it difficult to perceive how the possibility of confusion as to which DME facility to use for a final approach aid was reduced when a second nearby facility was added to the plate. Nevertheless, the precautionary note alerting pilots to the correct DME to use was deleted. We welcome the FAA project in conjunction with NOAA to determine if "the best means of charting information on an approach plate is being used," and believe it is a more realistic appraisal of the potential hazards involved than your specific determination that the Spokane "chart portrayal is adequate." We request that the FAA reconsider these three recommendations which we are classifying in an "Open-- Unacceptable Action" status.

From: FAA
To: NTSB
Date: 6/26/1981
Response: FAA LTR: THE FAA HAS COMPLETED A REVIEW OF APPROACH PROCEDURES WHERE DME IS INSTALLED AT A LOCALIZER. OUR EVALUATION OF THE PROCEDURES LEADS US TO CONCLUDE THAT THE CHART PORTRAYAL IS ADEQUATE. HOWEVER, WE SHARE THE BOARD'S CONCERN WITH RESPECT TO WHETHER THE BEST POSSIBLE MEANS OF CHARTING INFORMATION ON AN APPROACH PLATE IS BEING USED. ACCORDINGLY, THE FAA HAS INITIATED AN EFFORT, IN CONJUNCTION WITH THE NATIONAL OCEAN SURVEY, TO DETERMINE IF WE CAN IMPROVE ON THE EXISTING METHOD OF DEPICTION. CHANGES CURRENTLY BEING CONSIDERED INCLUDE: ADDITION OF THE LETTERS "LOC" AFTER THE IDENTIFICATION OF THE FACILITY FORMING THE FIX, I.E., IOLJ LOC DME; AND INCLUSION OF A NOTE TO THE PROFILE VIEW SIMILAR TO THAT DESCRIBED IN SAFETY RECOMMENDATION A-81-40.