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Safety Recommendation Details

Safety Recommendation A-90-124
Details
Synopsis: ON 9/8/89 N283AU, A BOEING 727-200 OPERATED AS USAIR FLIGHT 105 WAS A REGULARLY SCHEDULED REVENUE PASSENGER FLIGHT CONDUCTED UNDER 14 CODE OF FEDERAL REGULATIONS PART 121 FROM PITTSBURGH, PENNSYLVANIA (PIT), TO WICHITA, KANSAS, WITH AN EN ROUTE STOP IN KANSAS CITY, MISSOURI (MCI). FIFTY-EIGHT PASSENGERS, TWO FLIGHT CREWMEMBERS AND FOUR FLIGHT ATTENDANTS WERE ONBOARD. A FEDERAL AVIATION ADMINISTRATION INSPECTOR WHO WAS PERFORMING AN EN ROUTE INSPECTION OCCUPIED THE COCKPIT OBSERVER'S SEAT. THE FLIGHT FROM PITTSBURGH TO THE KANSAS CITY AREA WAS UNEVENTFUL. THE CAPTAIN WAS THE PILOT FLYING AND THE FIRST OFFICER WAS PERFORMING THE COMMUNICATIONS WITH AIR TRAFFIC CONTROL. USAIR 105 WAS CLEARED TO EXECUTE THE LOCALIZER BACK COURSE APPROACH TO RUNWAY 27 AT 2129:41. AT 2134:34, THE LOCAL CONTROLLER TOLD USAIR 105 "I" CAN'T TELL FOR SURE BUT IT APPEARS WE HAVE LOST THE LIGHTING ON THE SOUTH SIDE OF THE AIRPORT." THE FLIGHTCREW LATER DESCRIBED SEEING A BRIGHT FLASH ABOUT THIS TIME. SUBSEQUENT INSPECTION REVEALED THAT THE AIRPLANE STRUCK AND SEVERED FOUR ELECTRONIC TRANSMISSION CABLES, LOCATED ABOUT 75 FEET ABOVE THE GROUND, APPROXIMATELY 7,000 FEET EAST OF THE RUNWAY 27 THRESHOLD. THE FLIGHTCREW EXECUTED A MISSED APPROACH AND LANDED UNEVENTFULLY IN SALINA, KANSAS.
Recommendation: THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION: SOLICIT REPORTS FROM PILOTS ABOUT POTENTIALLY CONFUSING LIGHTS OR OTHER FEATURES NEAR RUNWAYS ASSOCIATED WITH INSTRUMENT APPROACH CHARTS THAT DO NOT DISPLAY CAUTIONARY WARNINGS ON THOSE FEATURES AND REQUIRE THAT THE APPROACH CHARTS BE REVISED TO INCORPORATE THE NEEDED WARNINGS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: KANSAS CITY, MO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA89IA071
Accident Reports: USAIR Flight 105 Boeing 737-200, N283AU
Report #: AAR-90-04
Accident Date: 9/8/1989
Issue Date: 9/28/1990
Date Closed: 2/3/1993
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 2/3/1993
Response: THE BOARD WAS AWARE OF THE FAA'S PROGRAM & POLICY TO IDENTIFY VISUAL HAZARDS NEAR RUNWAYS ASSOCIATED WITH INSTRUMENT APPROACH CHARTS. BECAUSE THE FAA HAS CONTACTED REPRESENTATIVES OF BOTH AIR CARRIER & GENERAL AVIATION ORGANIZATIONS TO REQUEST THAT THEY SOLICIT INPUT FROM THEIR MEMBERS CONCERNING THIS RECOMMENDATION, THE BOARD CLASSIFIES RECOMMENDATION A-90-124 "CLOSED--ACCEPTABLE ACTION."

From: FAA
To: NTSB
Date: 11/25/1992
Response: THE FAA CONTACTED REPRESENTATIVES OF BOTH AIR CARRIER AND GENERAL AVIATION ORGANIZATIONS TO REQUEST THAT THEY SOLICIT INPUT FROM THEIR MEMBERS. TO DATE, NO REPORTS HAVE BEEN RECEIVED. AS STATED IN THE FAA'S LETTER TO THE BOARD DATED DECEMBER 18, 1991, THE FAA'S PROGRAM AND POLICY TO IDENTIFY VISUAL HAZARDS NEAR RUNWAYS ASSOCIATED WITH INSTRUMENT APPROACH CHARTS MEET THE INTENT OF THIS SAFETY RECOMMENDATION. THE FAA ACTIVELY MAKES SAFETY RECOMMENDATIONS AS OUTLINED IN ORDER 8260-18A AND ADDRESSES EACH SITUATION AS IT IS IDENTIFIED.

From: NTSB
To: FAA
Date: 5/5/1992
Response: The Safety Board notes that the FAA is reluctant to include additional notations on approach charts that already contain substantial amounts of information. However, in accordance with FAA Order 8260.18A, the FAA does identify hazards to runway approaches and takes corrective action through visual approach aids such as the Visual Approach Slope Indicator (VASI) or Runway End Identifier Lights (REIL). We also note that the safety determinations of runway approaches are made regularly during the FAA's flight inspection of navigational aids. We further note that in this accident, even though the runway in Kansas City was equipped with VASI and REIL, the pilot failed to maintain a safe altitude and flight path. The FAA's letter did indicate that this safety recommendation was to be reviewed at Data Source: NTSB Recommendations to FAA and FAA Responses the FAA/Industry Charting Forum in February 1992. We would appreciate being informed as to what transpired at the meeting. Pending your further response, Safety Recommendation A-90-124 is classified as "Open--Acceptable Alternate Response."

From: FAA
To: NTSB
Date: 12/18/1991
Response: The FAA concurs with the intent of this safety recommendation that potentially confusing lights or other features near runways associated with instrument approach procedures be identified and that pilots be alerted to the hazard. The policy of the FAA, as stated in Order 8260.18A, Establishing Requirements for Visual Approach Aids, is to establish a Visual Approach Slope Indicator (VASI) or Runway End Identifier Lights (REIL) at runways where the natural environment either fails to provide the required reference or presents illusionary or false information to the pilot. A copy of this order accompanined our letter of December 18, 1990. Safety determinations of various runways are made regularly by flight standards inspectors, during flight inspection of navigation aids by flight inspection pilots, and as a result of recommendations from industry, which includes pilots. When a hazard is identified, appropriate action is taken in the form of a visual approach aid or a notation on an approach chart. However, notations on approach charts are kept to a minimum in order not to clutter already "busy" charts. Consequently, visual approach aids and operating aircraft in accordance with prescribed procedures address the users identified in this safety recommendation. Kansas City International Airport Runway 27 is equipped with a VASI and a REIL. The VASI would have provided appropriate guidance to the flightcrew had they complied with the regulations to maintain an altitude at or above the VASI glide slope until a lower altitude was necessary for a safe landing. The FAA's program and policy to identify visual hazards near runways associated with instrument approach charts meet the intent of this safety recommendation. The FAA actively makes safety recommendations as outlined in Order 8260.18A and addresses each situation as it is identified. The FAA will raise this safety recommendation at the FAA/Industry Charting Forum in February 1992. If a pilot solicitation is recommended and the results indicate a need for change, the FAA will pursue the best approach for providing this information. The FAA has met the full intent of this safety recommendation. There is an active program in place to identify the hazards cited by Safety Recommendation A-90-124 and an initiative to take appropriate corrective action when hazards are identified. Since any additional identification efforts which come from the February 1992 forum will be addressed through the current program, I believe this safety recommendation should be classified as "closed acceptable action."

From: NTSB
To: FAA
Date: 7/11/1991
Response: Safety Recommendation A-90-124 states that the FAA should solicit reports from pilots about potentially confusing lights or other features near runways and add warnings to instrument approach charts. The Safety Board notes that the FAA plans to conduct a joint FAA/Industry Charting Forum in the spring of 1991 and will raise the issue of ways to solicit pilot information about lights and other features. The FAA policy regarding use of a Visual Aid Slope Indicator (VASI) or a Runway End Identifier Light (REIL), when there are distracting or confusing lights near the end of the runway, may be viewed as an alternate form of correction if the FAA can show that the use of this equipment is responsive to pilots' concerns. Pending further information, Safety Recommendation A-90-124 is classified as "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 12/18/1990
Response: THE FAA PLANS TO CONDUCT A JOINT FAA/INDUSTRY CHARTING FORUM IN THE SPRING OF 1991 AND WILL RAISE THE ISSUE OF WAYS TO SOLICIT PILOTS. THE FAA POLICY TO SPECIFICALLY ADDRESS THIS ISSUE HAS BEEN TO ESTABLISH A VISUAL AID SLOPE INDICATOR (VASI) OR A RUNWAY END IDENTIFIER LIGHT (REIL) WHEN THERE ARE DISTRACTING OR CONFUSING LIGHTS NEAR THE END OF THE RUNWAY. I BELIEVE THIS POLICY MEETS THE INTENT.