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Safety Recommendation Details

Safety Recommendation A-90-126
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: REQUIRE THAT INSPECTORS HAVE CURRENT INSTRUMENT APPROACH CHARTS ACCESSIBLE TO THEM DURING THE CONDUCT OF EN ROUTE INSPECTIONS.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Reconsidered
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 - Reconsidered)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 7/11/1991
Response: Safety Recommendation A-90-126 states that the FAA should require inspectors to have current instrument approach charts accessible to them during the conduct of en route inspections. The Safety Board notes that the FAA implemented this safety recommendation on a trial basis rather than making it a permanent requirement. The FAA cited the results of the trial as reasons for its disagreement with the recommendation. The reasons include logistics of keeping complete current custom approach charts for each carrier that an inspector may serve, cockpit confusion arising from differences between inspectors' NOS charts and the commercially obtained approach charts used by flightcrews, and other problems. Based on the results of the trial program, Safety Recommendation A-90-126 is classified as "Closed--Reconsidered."

From: FAA
To: NTSB
Date: 12/18/1990
Response: THE OBJECTIVES OF THE EN ROUTE INSPECTION ARE THE EVALUATION OF FLIGHT CREW COMPETENCY, SURVEILLANCE OF TOTAL CARRIER OPERATIONS, EVALUATION OF ENTIRE AIR TRANPORTATION SYSTEM, & INVOLVEMENT OF FAA IN THE AIR TRANSPORTATION SYSTEM. COCKPIT CREWMEMBERS ARE TRAINED AS A TEAM & THE FAA DOES NOT ADVOCATE DISCUSSION WITH THE INSPECTOR. IF THE INSPECTOR SEES A QUESTIONABLE PROCEDURE, HE'S TO MENTION IT DURING DEBRIEFING, UNLESS IT IS A MATTER OF IMMINENT DANGER. THE INSPECTOR IS MONITORING CREW PERFORMANCE AS A WHOLE AND MAY NOT BE ABLE TO SEE THE INSTRUMENT PANEL. MANY AIRLINES PROVIDE THEIR CREWMEMBERS WITH CUSTOM APPROACH CHARTS, CONTAINING CUSTOM APPROACHES, MINIMA, ETC, WHICH THE INSPECTOR WOULD NOT HAVE. THE FAA INSPECTORS ARE FREQUENTLY ASSIGNED TO MORE THAN ONE CARRIER AND HAVE NOS CHARTS AVAILABLE WHICH WOULD NOT AGREE WITH THE CUSTOM JAPPESEN CHARTS. THE FAA BELIEVES THAT THE INSPECTOR SHOULD BE FAMILIAR WITH THE APPROACH PROCEDURES, BUT DOES NOT BELIEVE THAT THE INSPECTOR SHOULD BE USING THE CHART DURING AN INSPECTION. AS A RESULT OF THIS INCIDENT AND AS A TRAIL, SOME INSPECTORS WERE GIVEN NOS CHARTS FOR EN ROUTE INSPECTIONS. IT WAS DETERMINED THAT THIS WAS DISRUPTIVE AND CUMBERSOME. THE COORDINATION REQUIRED TO DISCUSS DIFFERENCES BETWEEN THE NOS CHARTS AND THE CUSTOM JAPPESEN WAS ESPECIALLY DISRUPTIVE. AT THE COMPLETION OF THE TRAIL PROGRAM, THE PRACTICE WAS DETERMINED TO BE IMPRACTICAL. I PLAN NO FURTHER ACTION.