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Safety Recommendation Details

Safety Recommendation A-82-093
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: ASSIGN PERSONNEL TRAINED IN HUMAN ENGINEERING AND HUMAN PERFORMANCE TO THE INTERAGENCY AIR CARTOGRAPHIC COMMITTEE AND THE INTRA-AGENCY COMMITTEE FOR FLIGHT INFORMATION.
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: 9/28/1989
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/28/1989
Response: The Safety Board has reviewed the file associated with this safety recommendation and agrees that, as stated in our letter of February 28, 1983, the assignment of a person to the IACC would not be appropriate. Therefore, the status of Safety Recommendation A-82-93 has been changed to "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 5/15/1989
Response: (SUMMARIZED) THE FAA TOLD THE SAFETY BOARD IN A LETTER OF NOVEMBER 17, 1982, THAT IT WOULD ASSIGN A HUMAN PERFORMANCE SPECIALIST TO THE INTRA-AGENCY COMMITTE FOR FLIGHT INFORMATION (IACFI), BUT THAT IT WOULD NOT ASSIGN A PERSON TO THE INTERAGENCY AIR CARTOGRAPHIC COMMITTEE (IACC). THE FAA PROVIDED ITS RATIONALE IN THE SAME LETTER, WHICH THE SAFETY BOARD AGREED WITH IN A LETTER OF FEBRUARY 28, 1983. THE RECOMMENDATION WAS LEFT "OPEN" PENDING ASSIGNMENT OF A HUMAN FACTORS PERSON TO THE IACFI. ON JUNE 13, 1985, THE FAA NOTIFIED THE BOARD THAT IT HAD ASSIGNED A HUMAN FACTORS PERSON TO THE IACFI AND THAT THE FAA ACTION WAS COMPLETE. ON AUGUST 19, 1985, THE SAFETY BOARD CONTRADICTED ITS LETTER OF FEBRUARY 28, 1983, SAYING THAT THE APPOINTMENT WAS PARTIAL FULLFILLMENT, AND THAT THE RECOMMENDATION WOULD BE HELD "OPEN ACCEPTABLE" PENDING AN ASSIGNMENT TO IACC. THE FAA DOES NOT INTEND TO ASSIGN A PERSON TO THE IACC SINCE IACC IS SIGNATORY ONLY AND DOES NOT PERFORM IN-DEPTH REVIEW OR EVALUATION OF PROPOSED CHANGES ON CHARTS. THE IACFI IS RESPONSIBLE FOR ALL REVIEW AND EVALUATION OF PROPOSED CHANGES. IACC RELIES ON IACFI AND THE FLIP COORDINATING COMMITTEE (FCC). FCC IS THE DEFENSE MAPPING AGENCY COUNTERPART TO IACFI.

From: NTSB
To: FAA
Date: 11/8/1988
Response: Please provide us with a report on the status of actions to implement the National Transportation Safety Board's Safety Recommendation A-82-93, concerning human performance engineering and human factors in the areas of cartography and flight information. The FAA last responded to this Safety Recommendation in a letter dated June 13, 1985, to which the Safety Board replied on August 19, 1985. This safety recommendation is being maintained in an "Open--Acceptable Action" status.

From: NTSB
To: FAA
Date: 8/19/1985
Response: The Safety Board considers the appointment of a professional in human performance to the Intra-Agency Committee on Flight Information to be in partial fulfillment of this recomendation. While your letter mentioned that the FAA representative has been an active member on a number of task groups which reviewed and issued recommendations for improving many civil aeronautical charts, we believe still that the human factors aspects of aeronautical chart design could be improved by assigning a similarly qualified person to the Interagency Air Cartographic Committee. Safety Recommendation A-82-93 has been classified as "Open--Acceptable Action," pending notification that the FAA has taken action more specifically directed at improving charting, e.g., that a person trained in human factors engineering and human performance has been assigned to the Interagency Air Cartographic Committee or that a suitable study of aeronautical charts has moved out of the proposal stage. Your efforts to respond to our recommendations are appreciated.

From: FAA
To: NTSB
Date: 6/13/1985
Response: FAA LETTER: DR. ALAN E. DIEHL, A PROGRAM SCIENTIST IN THE FAA'S BIOMEDICAL AND BEHAVIORAL SCIENCES DIVISION, OFFICE OF AVIATION MEDICINE, HAS BEEN APPOINTED TO THE INTRA-AGENCY COMMITTEE ON FLIGHT INFORMATION (IACFI) AS THAT COMMITTEE'S HUMAN PERFORMANCE SPECIALIST. DR. DIEHL, WHO FORMERLY SERVED AS AN NTSB TECHNICAL STAFF MEMBER, HAS A PH.D. IN HUMAN FACTORS ENGINEERING AND HAS EXTENSIVE AVIATION EXPERIENCE. SINCE BECOMING AN IACFI MEMBER, DR. DIEHL HAS PARTICIPATED IN ALL COMMITTEE MATTERS CONCERNING AERONAUTICAL INFORMATION PUBLICATIONS. IN ADDITION, HE SERVED AS HUMAN PERFORMANCE TECHNICAL EXPERT ON A NUMBER OF NAR TASK GROUPS WHICH REVIEWED AND ISSUED RECOMMENDATIONS FOR IMPROVING THE ENTIRE SERIES OF GOVERNMENT CIVIL AERONAUTICAL CHARTS. DR. DIEHL HAS ALSO BEEN NAMED THE FAA'S TECHNICAL CONTACT ON HUMAN PERFORMANCE ENGINEERING MATTERS RELATED TO A PROPOSED STUDY OF AERONAUTICAL CHARTS, INSTRUMENTS APPROACH PROCEDURE DESIGN CRITERIA, AND PROCEDURE DEVELOPMENT AND CONSTRUCTION, INTERALIA. IN LIGHT OF DR. DIEHL'S SERVICE ON THE IACFI AND HIS INVOLVEMENT IN OTHER SUBSTANTIVE FAA ACTIVITIES RELATED TO AERONAUTICAL CHARTING, WE CONSIDER OUR ACTIONS ON THIS RECOMMENDATION COMPLETED.

From: NTSB
To: FAA
Date: 2/28/1983
Response: The Safety Board concurs with your response regarding the Interagency Air Cartographic Committee (IACC). However, the Board requests that the IACC be made aware of our response and urges the individual members of this committee to insure that, within their respective agencies, human performance considerations in the design of approach procedures and/or charts are actively pursued and thoroughly addressed. The Safety Board hopes that the FAA soon will appoint a human performance specialist to the Intra-Agency Committee for Flight Information. Until such time as this person is appointed and is actively engaged in his/her specialty in this committee, Safety Recommendation A-82-93 will be held in an "Open-- Acceptable Action" status.

From: FAA
To: NTSB
Date: 11/17/1982
Response: FAA LETTER: IN VIEW OF ITS LIMITED FUNCTION AND INTENDED ROLE IN CARTOGRAPHIC MATTERS, THE IACC IS NOT AN APPROPRIATE COMMITTEE FOR THE ASSIGNMENT OF PERSONNEL TRAINED IN HUMAN ENGINEERING AND HUMAN PERFORMANCE AS RECOMMENDED BY THE SAFETY BOARD. FUNCTIONS SUSCEPTIBLE TO THE APPLICATION OF HUMAN FACTORS SKILLS ARE PERFORMED BY THE FAA AND DEFENSE MAPPING AGENCY (DMA) IN FULFILLING THEIR ROLES IN THE CHARTING SYSTEM. THESE FUNCTIONS INCLUDE IDENTIFICATION, VALIDATION, AND PRIORITIZATION OF REQUIREMENTS; DEVELOPMENT OF PRODUCT STANDARDS; AND DEVELOPMENT OF CHART DESIGN. IT IS OUR INTENT TO IDENTIFY A REPLACEMENT HUMAN FACTORS RESOURCE INDIVIDUAL FOR MEMBERSHIP ON THE INTRA-AGENCY COMMITTEE ON FLIGHT INFORMATION (IACFI) AND HAVE TAKEN STEPS TO INVOLVE THAT REPRESENTATIVE IN DETERMINATIONS CONCERNING AIR CARTOGRAPHIC MATTERS.