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Safety Recommendation Details

Safety Recommendation A-90-129
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: ISSUE AN AIR CARRIERS OPERATIONS BULLETIN DIRECTING PRINCIPAL OPERATIONS INSPECTORS TO URGE AIR CARRIERS TO ENSURE THAT FLIGHTCREWS ARE COGNIZANT OF THE PURPOSE OF VISUAL DESCENT POINTS AND TO INCLUDE APPROACHES WITH VISUAL DESCENT POINTS IN THEIR SIMULATOR TRAINING.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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: 4/29/1992
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Flightcrew, Simulator, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/29/1992
Response: The Safety Board is pleased to note that on July 29, 1991, the FAA issued ACOB 7-91- 1, Training Emphasis on the Purpose and Utilization of Visual Descent Points (VDP's) on Straight-in Nonprecision Approach Procedures. This bulletin directs principal operations inspectors to urge their assigned air carriers to ensure that flightcrews are cognizant of the purpose of VDPs and include approaches with VDPs in their simulator or aircraft training programs. Safety Recommendation A-90-129 is now classified as "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 10/9/1991
Response: ON 7/29/91 THE FAA ISSUED ACOB 7-91-1, TRAINING EMPHASIS ON THE PURPOSE AND UTILIZATION OF VISUAL DESCENT POINTS (VDP) ON STRAIGHT-IN NONPRECISION APPROACH PROCEDURES. THIS BULLETIN DIRECTS PRINCIPAL OPERATIONS INSPECTORS TO URGE THEIR ASSIGNED AIR CARRIERS TO ENSURE THAT FLIGHTCREWS ARE COGNIZANT OF THE PURPOSE OF VDPS AND INCLUDE APPROACH WITH VDPS IN THEIR SIMULATOR OR AIRCRAFT TRAINING PROGRAMS.

From: NTSB
To: FAA
Date: 7/11/1991
Response: Safety Recommendation A-90-129 states that the FAA should urge air carriers to ensure that flightcrews are cognizant of the purpose of VDPs and to include approaches with VDPs in simulator training. Safety Recommendation A-90-131 states that the FAA should direct principal operations inspectors to verify that the airlines they surveil have clearly established stabilized approach and missed approach procedures for nonprecision approaches, such as full-scale deflection of the localizer needle when the airplane is inside the final approach fix. The Safety Board notes that the FAA agrees with these safety recommendations and will issue or modify air carrier operations bulletins. Safety Recommendations A-90-129 and -131 are classified as "Open--Acceptable Response," pending information that the appropriate bulletins have been issued or modified.

From: FAA
To: NTSB
Date: 12/18/1990
Response: THE FAA AGREES AND WILL MODIFY ACOB 7-76-31 TO INCLUDE REFERENCES TO VISUAL DESCENT POINTS. I WILL PROVIDE THE BOARD.