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Safety Recommendation Details

Safety Recommendation A-82-091
Details
Synopsis: ON JANUARY 20, 1981, A CASCADE AIRWAYS, INC. BEECH 99A AIRCRAFT EN ROUTE FROM MOSES LAKE, WASHINGTON, TO SPOKANE, WASHINGTON, CRASHED ABOUT 4.5 MILES SOUTHWEST OF SPOKANE INTERNATIONAL AIRPORT. THE ACCIDENT OCCURRED WHILE THE PILOT WAS MAKING A LOCALIZER INSTRUMENT APPROACH TO RUNWAY 3. SEVEN PERSONS INCLUDING THE FLIGHTCREW WERE KILLED, AND TWO PASSNEGERS WERE INJURED SERIOUSLY.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: ESTABLISH FORMAL HUMAN PERFORMANCE CRITERIA FOR THE DEVELOPMENT AND EVALUATION OF INSTRUMENT APPROACH PROCEDURES AND INSTRUMENT APPROACH CHARTS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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: 8/18/1982
Date Closed: 3/26/1987
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/26/1987
Response: The Safety Board is concerned that the FAA has not provided the formal human performance criteria requested by this recommendation. However, the Board notes that the National Airspace Review (NAR) task group, of which the FAA is a member, has found the existing National Oceanic and Atmospheric Administration specifications for the development and evaluation of instrument approach procedures and instrument approach charts to be satisfactory. The Board further notes that the NAR findings were developed after the August 18, 1982, issue date of recommendation A-82-91 and, therefore, has decided to accept the task group's findings as a good faith response to the intent of this recommendation. Therefore, we have classified Safety Recommendation A-82-91 as "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 12/15/1986
Response: THE PROPOSED CHART REVISIONS WERE DEVELOPED BY THE NATIONAL AIRSPACE REVIEW (NAR) TASK GROUP CONSISTING OF PILOTS, CARTOGRAPHERS, AIR TRAFFIC CONTROLLERS, AND INSTRUMENT PROCEDURES SPECIALISTS AS MEMBERS OR ADVISERS. THE GROUP WAS ADVISED IN HUMAN FACTORS BY DR. ALAN DIEHL, PH. D., BIOMEDI CAL AND BEHAVIORAL SCIENCES DIVISION, OFFICE OF AVIATION MEDICINE, FAA WHO WAS A MEMBER OF THE NAR TASK GROUP. THE FIRST TWO PAGES OF THE BOOKLET LIST THE SPECIFIC CHANGES. THE NAR TASK GROUP REVIEWED THE NOAA SPECIFICATIONS FOR HUMAN ENGINEERING AND PERFORMANCE. THESE SPECIFICATIONS ARE BASED ON EXISTING HUMAN PERFORMANCE CRITERIA WHICH WERE DEVELOPED OVER THE YEARS FOR CHART CONSTRUCTION. THE TASK GROUP FOUND THE EXISTING SPECIFICATIONS SATISFACTORY.

From: NTSB
To: FAA
Date: 8/21/1986
Response: Accompanying your letter were prototype approach chart enhancements prepared by the Department of Commerce. The Safety Board would appreciate being informed what human performance criteria were used in the revision of these charts and what specific changes have been made. We thank you for your offer to provide us with a copy of the finalized instrument approach charts when they become available. Pending your further response, this recommendation is classified as "Open--Acceptable Action."

From: FAA
To: NTSB
Date: 7/14/1986
Response: "ATTACHED FOR THE BOARD'S INFORMATION ARE PROTOTYPE INSTRUMENT APPROACH ENHANCEMENTS PROPOSED BY THE NATIONAL AIRSPACE REVIEW. THESE CHARTS WERE PREPARED BY THE DEPARTMENT OF COMMERCE AND WERE DISTRIBUTED TO USERS FOR COMMENT. I WILL PROVIDE THE BOARD WITH A FINALIZED INSTRUMENT APPROACH CHARTS WHEN THEY BECOME AVAILABLE."

From: NTSB
To: FAA
Date: 5/6/1986
Response: We would appreciate receiving copies of materials currently being prepared jointly by the FAA and the Department of Commerce. Pending your further response, this recommendation is classified "Open--Acceptable Action."

From: FAA
To: NTSB
Date: 3/6/1986
Response: "THE FAA WITH THE COOPERATION OF THE UNITED STATES DEPARTMENT OF COMMERCE HAS DEVELOPED A SERIES OF PROTOTYPE AERONAUTICAL CHARTS. THE PROTOTYPE CHART ENHANCEMENTS ARE BASED ON RECOMMENDATIONS RECEIVED FROM FAA CARTOGRAPHERS, PROCEDURE SPECIALISTS, AND HUMAN FACTOR SPECIALISTS THAT ARE WORKING IN CONJUNCTION WITH PARTICIPANTS IN THE FAA'S NATIONAL AIRSPACE REVIEW (NAR). THE STATUS OF ACTION RELATIVE TO THE VARIOUS CHARTS IS AS FOLLOWS: A. THE VISUAL FLIGHT RULES PROTOTYPE CHART EVALUATION IS COMPLETED AND THE RESULTING RECOMMENDATIONS HAVE BEEN SENT TO THE INTERAGENCY AIR CARTOGRAPHIC COMMITTEE FOR ITS REVIEW. B. THE PROTOTYPE INSTRUMENT FLIGHT RULES EN ROUTE CHARTS HAVE BEEN CIRCULATED FOR COMMENT AND THE RESULTS ARE BEING EVALUATED. C. THE PROTOTYPE APPROACH CHARTS HAVE HAD INITIAL REVIEW. A BOOKLET IS BEING PREPARED SHOWING THE NAR RECOMMENDED FORMAT CHANGES FOR THE U.S. GOVERNMENT STANDARD INSTRUMENT APPROACH PROCEDURES BOUND VOLUMES. THE PROTOTYPE APPROACH CHARTS WILL BE INCLUDED. THIS BOOKLET WILL BE USED FOR ADDITIONAL EVALUATION. I CONSIDER THESE ACTIONS TO BE RESPONSIVE TO THE BOARDS RECOMMENDATION".

From: NTSB
To: FAA
Date: 8/19/1985
Response: The Safety Board is pleased to learn of the plans the FAA has developed to improve the human factors aspects of instrument procedures design and charting. While the Safety Board supports the actions proposed in your letter, we are concerned about the length of time it has taken to develop these plans. On May 1, 1984, a Piper PA- 23-250, N63813, crashed near Ukiah Municipal Airport, Ukiah, California. The human factors aspects of this accident, as related to the approach procedures and approach charts, were very similar to those of the accident near Spokane, Washington. The Safety Board understands that there are approximately 105 other approach charts that have human factor design problems similar to those on the charts for Spokane, Washington, and Ukiah, California. Some five or six of these involve airports located in areas of "hazardous terrain." The Safety Board believes that the matter of human factors considerations in developing instrument approaches and approach charts is a critical one that deserves more attention than the FAA's action over the past 3 years indicates has been the case. The Safety Board looks forward to reviewing the status report on this effort, projected to be released by mid-September 1985, and hopes that further action in this area will be expeditious. Pending our review of the projected status report, Safety Recommendations A-82-91 and -92 have been classified as "Open--Acceptable Action."

From: FAA
To: NTSB
Date: 6/13/1985
Response: FAA LETTER: THE FEDERAL AVIATION ADMINISTRATION'S (FAA) CARTOGRAPHERS, PROCEDURES SPECIALISTS, AND OUR HUMAN FACTORS SPECIALIST HAVE PARTICIPATED EXTENSIVELY IN THE NATIONAL AIRSPACE REVIEW (NAR) TASK GROUPS ON AERONAUTICAL CHARTING, INCLUDING INSTRUMENT APPROACH PROCEDURES. IN ADDITION, THROUGH THE COOPERATION OF THE UNITED STATES DEPARTMENT OF COMMERCE, NEW PROTOTYPE CHARTS HAVE BEEN DEVELOPED WHICH ARE BEING EVALUATED FOR HUMAN PERFORMANCE IMPROVEMENT. THIS IS PART OF A LARGER EFFORT WHICH INCLUDES VISUAL FLIGHT RULES (VFR) CHARTS AND INSTRUMENT FLIGHT RULES (IFR) EN ROUTE CHARTS. THE VFR CHART EVALUATION IS NEARING COMPLETION. WE ARE NOW IN THE PROCESS OF CONTRACTING FOR STUDIES TO IMPROVE THE HUMAN FACTORS ASPECTS OF THE INSTRUMENT PROCEDURES DESIGN AND CHARTING. THE FAA'S AVIATION STANDARDS NATIONAL FIELD OFFICE IS PLANNING ON REVISING THE GUIDANCE MATERIAL IN FAA ORDER OA P 8200.1, UNITED STATES STANDARD FLIGHT INSPECTION MANUAL, SECTION 214, FLIGHT INSPECTION OF INSTRUMENT FLIGHT PROCEDURES, TO PROVIDE MORE HUMAN PERFORMANCE CONSIDERATIONS. WE WILL PROVIDE THE BOARD WITH A STATUS REPORT OF OUR ACTIONS AND PROGRESS IN 90 DAYS.

From: NTSB
To: FAA
Date: 2/28/1983
Response: Your letter states that the FAA has undertaken a review of the areas addressed in these two recommendations. The Safety Board looks forward, in May 1983, to the findings resulting from this review and the proposed actions the FAA may initiate. Additional support for these two recommendations was generated from the incident data bank of the National Aeronautics and Space Administration (NASA) Aviation Safety Reporting System (ASRS). NASA has identified numerous ASRS reports in which approach procedure and approach chart issues played a significant role in the occurrence of the incident. The Safety Board has established a continuing dialogue regarding these issues with several user groups. Through this dialogue, we have discovered categories of human factors problems that include confusion, complexity, clutter, inadequate criteria or information, and lack of standardized symbology which occur in some approach procedures and charts. The Safety Board urges the FAA to take positive steps to formally incorporate human performance evaluations into the design of approach procedures and charts. The Safety Board intends to actively pursue the intent of these recommendations to insure positive action by all concerned parties. Recommendations A-82-91 and -92 have been classified in an "Open--Acceptable Action" status.

From: FAA
To: NTSB
Date: 11/17/1982
Response: FAA LETTER: MUCH OF THE FAA'S EFFORT IN INSTRUMENT APPROACH PROCEDURES DEVELOPMENT PROCESS HAS BEEN DEVOTED TO ACHIEVING FLYABLE PROCEDURES WITH REASONABLE PILOT WORKLOADS AND ASSURING THAT THESE PROCEDURES ARE DEPICTED ON CHARTS THAT ARE EASY TO UNDERSTAND. THESE HUMAN PERFORMANCE CONSIDERATIONS HAVE BEEN THE RESPONSIBILITY OF EXPERIENCED AIRSPACE SYSTEM INSPECTION PILOTS, AERONAUTICAL INFORMATION SPECIALISTS, AND CARTOGRAPHERS. TO BE MORE RESPONSIVE TO THE BOARD'S RECOMMENDATIONS, THE FAA HAS UNDERTAKEN A REVIEW OF THE SUBJECT AREA ADDRESSED IN RECOMMENDATIONS A-82-91 AND A-82-92. WE EXPECT THIS REVIEW TO BE COMPLETED IN APPROXIMATELY 6 MONTHS.