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Safety Recommendation Details

Safety Recommendation A-90-125
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: MODIFY THE FUNCTIONAL STATEMENT OF THE FEDERAL AVIATION ADMINISTRATION OFFICE OF SAFETY QUALITY ASSURANCE AND PROVIDE SUFFICIENT RESOURCES TO IT TO MAKE IT CAPABLE OF PROVIDING EFFECTIVE QUALITY ASSURANCE AND SAFETY OVERSIGHT OF THE AIR TRAFFIC CONTROL SYSTEM. (Supersedes Safety Recommendation A-89-041)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 7/11/1991
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/11/1991
Response: Safety Recommendation A-90-125 states that the FAA should modify the functional statement of the FAA Office of Safety Quality Assurance (OSQA) and provide sufficient resources to make the office capable of providing effective quality assurance and safety oversight of the air traffic control (ATC) system. The Safety Board notes that the FAA rejects this safety recommendation, referring to the FAA letter of August 17, 1989, which responded to Safety Recommendation A-89-41. Safety Recommendation A-89-41 was superseded by Safety Recommendation A-90-125. Safety Recommendation A-89-41 addressed the need to implement, adequately staff, and fund the OSQA to monitor the ATC system and other programs to ensure that operational and managerial deficiencies are identified and corrected. The Safety Board letter of January 22, 1990, noted that when the FAA established the OSQA, it was to be staffed by only 19 people in two divisions and that only 2 people were to be dedicated to ATC problems. The Safety Board understands the FAA position that overall quality and safety oversight functions should be assigned to the Office of Air Traffic System Effectiveness for regular daily operations. However, the Safety Board continues to believe that OSQA staffing is inadequate to accomplish its proper monitoring function. Additionally, the Safety Board notes that the OSQA has not been recognized as a formal component within the structure of the FAA. The superseding of Safety Recommendation A-89-41 by A-90-125 was described in the Safety Board's letter of January 28, 1991, as a need "to reiterate the Safety Board's concern regarding the need for strengthening the OSQA." Safety Recommendation A-89-41 was changed to "Closed--Unacceptable Action/Superseded" when Safety Recommendation A-90-125 was issued. As documented by the correspondence of the last 2 years, the Safety Board does not agree with the FAA position that the OSQA monitoring of the oversight and management of the ATC system "is staffed adequately and empowered to accomplish its mission." Therefore, Safety Recommendation A-90-125 is classified as "Closed--Unacceptable Action."

From: FAA
To: NTSB
Date: 12/18/1990
Response: AS STATED IN THE FAA RESPONSE OF AUGUST 17, 1989, TO SAFETY RECOMMENDATION A-89-41, THE FAA BELIEVES THAT THE OFFICE OF SAFETY QUALITY ASSURANCE IS PROPERLY ESTABLISHED AND ACCOMPLISHING ITS DUTIES IN AN EFFECTIVE MANNER. I CONSIDER THE FAA'S ACTION TO BE COMPLETED.