Skip Ribbon Commands
Skip to main content
Safety Recommendation Details

Safety Recommendation A-82-092
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 HUMAN PERFORMANCE CHECKLISTS OR GUIDELINES FOR USE BY PROCEDURES SPECIALISTS AND FLIGHT INSPECTIONS PILOTS WHEN EVALUATING NEW APPROACH PROCEDURES.
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 has reviewed the revised Action Notice 8200.2 and finds that the intent of this recommendation has been met. Safety Recommendation A-82-92 has been classified as "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 12/15/1986
Response: THE FAA HAS DRAFTED A REVISION TO SECTION 214 OF THE UNITED STATES STANADARD FLIGHT INSPECTION MANUAL TO INCORPORATE HUMAN FACTORS MATERIAL. DR. CARL MELTON, PH.D., A HUMAN FACTORS CONSULTANT TO THE FAA, PROVIDED EXPERTISE IN THE REVISION OF THIS SECTION. THE CONTENTS OF THE REVISED SECTION 214 HAVE BEEN IMPLEMENTED IN AN ACTION NOTICE 8200.2, FLIGHT INSPECTION OF INSTRUMENT FLIGHT PROCEDURES, AND WILL BE INCLUDED IN CHANGE 45 TO THE FLIGHT INSPECTION MANUAL.

From: NTSB
To: FAA
Date: 8/21/1986
Response: We note that the FAA is drafting Change 45 to Section 214 of the Flight Inspection Manual, and that this change will provide more human performance considerations for use by flight inspection pilots when evaluating new and existing approach procedures. Pending your further response, this recommendation is also held in an "Open--Acceptable Action" status.

From: FAA
To: NTSB
Date: 7/14/1986
Response: "THE FAA'S AVIATION ADMINISTRATION'S AVIATION STANDARDS NATIONAL FIELD OFFICE IS NOW DRAFTING CHANGE 45 TO SECTION 214 OF THE FLIGHT INSPECTION MANUAL. THIS CHANGE WILL PROVIDE MORE HUMAN PERFORMANCE CONSIDERATIONS FOR USE BY FLIGHT INSPECTION PILOTS WHEN EVALUATING NEW AND EXISTING APPROACH PROCEDURES. IT IS ANTICIPATED THAT THIS CHANGE WILL BE FINALIZED BY OCTOBER 1, 1986, AND I WILL PROVIDE THE BOARD WITH A COPY SHORTLY THEREAFTER."

From: NTSB
To: FAA
Date: 5/6/1986
Response: We note the FAA Order OA P 8200.1, U.S. Standard Flight Inspection Manual, is being revised to provide more human performance considerations, and that studies will be undertaken to improve the human factor aspects of instrument procedures design and Data Source: NTSB Recommendations to FAA and FAA Responses charting. We appreciate your offer to provide the Safety Board with a progress report. This recommendation is also classified "Open--Acceptable Action."

From: FAA
To: NTSB
Date: 3/6/1986
Response: "THE FAA'S AVIATION STANDARDS NATIONAL FIELD OFFICE IS PRESENTLY REVISING THE GUIDANCE MATERIAL IN FAA ORDER OA P 8200.1, U.S. STANDARD FLIGHT INSPECTION MANUAL, SECTION 214, FLIGHT INSPECTION OF INSTRUMENT FLIGHT PROCEDURES TO PROVIDE MORE HUMAN PERFORMANCE CONSIDERATIONS. IN ADDITION, DR. CARL MELTON, PHD., A SPECIALIST IN HUMAN FACTORS, IS CONTRIBUTING TO THIS EFFORT THROUGH A CONTRACT WITH THE FAA'S OFFICE OF AVIATION MEDICINE. I ANTICIPATE THAT THIS EFFORT WILL BE COMPLETED BEFORE OCTOBER 1, 1986. IN ADDITION TO THE ABOVE ACTIONS, I PLAN TO INITIATE A CONTRACT FOR STUDIES TO IMPROVE THE HUMAN FACTOR ASPECTS OF INSTRUMENT PROCEDURES DESIGN AND CHARTING BEFORE APRIL 1, 1986. I WILL PROVIDE THE BOARD WITH A STATUS REPORT OF THE FAA'S ACTIONS AND PROGRESS IN 90 DAYS."

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 as "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.