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Safety Recommendation Details

Safety Recommendation A-91-122
Details
Synopsis: ON DECEMBER 26, 1989, UNITED EXPRESS, FLIGHT 2415 (SUNDANCE 415), A BRITISH AEROSPACE BA-3101 JETSTREAM, N41OUE, CRASHED APPROXIMATELY 400 FEET SHORT OF RUNWAY 21R AT TRI-CITIES AIRPORT, PASCO, WASHINGTON. THE AIRPLANE CRASHED WHILE EXECUTING AN INSTRUMENT LANDING SYSTEM (ILS) APPROACH TO THE RUNWAY AT APPROXIMATELY 2230 PACIFIC STANDARD TIME. VISUAL METEOROLOGICAL CONDITIONS PREVAILED BENEATH THE CLOUD BASES, WHICH WERE APPROXIMATELY 1,000 FEET ABOVE GROUND LEVEL AT THE TIME OF THE ACCIDENT. THE AIRPLANE WAS DESTROYED, AND THE TWO PILOTS AND ALL FOUR PASSENGERS RECEIVED FATAL INJURIES.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Issue an operations bulletin to the principal operations inspectors of 14 CFR 121 and Part 135 air carriers to verify that air carriers have established procedures for flightcrews to take appropriate actions when they have encountered icing conditions during a flight, to check for the presence of, and to rip airplanes of accumulated airframe ice prior to initiating final approach, in accordance with airplane manufacturers' recommendations on the use of deice systems. (superseded by A-94-71)
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action/Superseded
Mode: Aviation
Location: PASCO, WA, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA90MA011
Accident Reports: Unstabilized Approach and Loss of Controll NPA, Inc. dba United Express Flight 2415 British Aerospace BA-3101, N410UE
Report #: AAR-91-06
Accident Date: 12/26/1989
Issue Date: 11/19/1991
Date Closed: 3/17/1994
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action/Superseded)
Keyword(s): Icing, Weather

Safety Recommendation History
From: NTSB
To: FAA
Date: 3/17/1994
Response: THE BOARD IS ALSO CONCERNED THAT OTHER ACOBS ISSUED IN THE RECENT PAST MIGHT NOT HAVE RESULTED IN THE INTENDED CORRECTIVE ACTIONS. MANY OF THE BOARD'S PREVIOUS RECOMMENDATIONS HAVE URGED CORRECTIVE ACTIONS THAT WERE REPORTEDLY IMPLEMENTED BY MEANS OF ACOBS THAT DIRECTED POIS TO ACCOMPLISH SPECIFIC TASKS. IN MOST CASES, THE BOARD CLASSIFIED RECOMMENDATIONS A-91-122, A-92-59, A-92-60, AND A-92-61 AS "CLOSED--ACCEPTABLE ACTION/SUPERSEDED" BY A-94-71. BASED ON A REVIEW OF THE GUIDANCE CONTAINED IN THE PUBLISHED ACOBS AND ASSUMING THAT THE ACTIONS DIRECTED AT POIS HAD BEEN ACCOMPLISHED. THE BOARD HAS NOT PREVIOUSLY ATTEMPTED TO VERIFY WHETHER THE ACTIONS DIRECTED BY THE ACOBS HAD ACTUALLY BEEN TAKEN. IN VIEW OF THE FINDINGS OF THE CURRENT INVESTIGATIONS, THE BOARD BELIEVES THAT THE FAA SHOULD UNDERTAKE A PROGRAM TO REVIEW ALL ACOBS THAT HAVE BEEN ISSUED IN THE PAST FEW YEARS TO ENSURE THAT THE INTENDED ACTIONS HAVE ACTUALLY BEEN TAKEN.

From: NTSB
To: FAA
Date: 4/10/1992
Response: Safety Recommendations A-91-88 through -90 and A-91-122 also pertain to aircraft ice protection. We note that the FAA agrees with these safety recommendations and is taking action towards their satisfactory resolution. Pending the FAA's further response, these safety recommendations are classified as "Open--Acceptable Response."

From: FAA
To: NTSB
Date: 1/31/1992
Response: THE FAA AGREES WITH THIS SAFETY RECOMMENDATION AND IS DEVELOPING AN AIR CARRIER OPERATIONS BULLETIN TO ADDRESS THIS SAFETY RECOMMENDATION.