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Usair Flight 1016, a DC-9-31, Which Crashed Near the Charlotte/Douglas International Airport, Charlotte, North Carolina, on .Luly 2, 1994

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Usair Flight 1016, a DC-9-31, Which Crashed Near the Charlotte/Douglas International Airport, Charlotte, North Carolina, on .Luly 2, 1994 3 r . ii! 4 F z \ \ \ I -- _. - NTSB/AAR-95/03 PB959 10403 NATIONAL TRANSPORTATION SAFETY BOARD - WASHINGTON, D.C. 20594 _ -~ .~ AIRCRAFT AWPENT REPORT FLIGHT MT0 TERRAIN DURING MISSED APPROACH USAIR FLIGHY 1016, DC-9-31, N954VJ CHARLOTTE/DOUGLAS INTERNATIONAL AIRPORT CHARLOll-E, NORTkl CAROLINA JULY 2,1994 Adopted; April 4,1996- Notation 6413A - - PROTECTED UNDER Hll%NATKlNAL COWRIGHT ALl. RIGHTS RESERVED. NATIONAL TECHNICAL INFOAMATKW SERVICE U.S. DEPARTMENT OF COMMERCE Abstract: This report explains the accident involving USAir flight 1016, a DC-9-31, which crashed near the Charlotte/Douglas International Airport, Charlotte, North Carolina, on .luly 2, 1994. Safety issues in the report include standard operating procedures for flightcrews and air traffic controllers, the dissemination of weather information to flightcrews, and flightcrew training. Safety recommendations concerning these issues were made to the Federal Aviation Administration, USAir, and the National Weather Service. - The National Transportation Safety Board is an^‘independent Federal agency dedicated tx~ promoting aviation, railroad, highway, marine, pipeline, and hazudous materials safety. Establishedi in 196?, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes sb _ --. the accidents, issue safety recommendations,.- study transportation safety issues, and evaluate _ _ _ the safety effectiveness of government agencies involved in transportation. The Safctjf Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available pubiications may be obtained by contacting: National Transportation Safety Board Public Inquiries Section, RE-51 490 L’Enfant Plaza, S.W. Washington, D.C. 20594 (202)382-6735 Safety Board publications may be purchased, by individual copy or by subsctiption, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 - - --- -- - _ .... CONTENTS EXECUTIVE SCJMMARY .......................... ..................................... vi FACTUAL INFORhlATION History of Flight. ......... ......................................................................... 1 1.1.1 Statements of Witnesses.. ............................................ ......................... 7 I .2 injuries to Persons ............................................... .............................. 8 1.3 Damage to the Airplane ................................. .............................. ........ 8 1.4 @her Damage ............................. .......... I._“‘I.. ...................... .....................~ 8- .4c Personnel information.. .................................. ...................................... 8 i’ .5.1 The Captain.. ......................................................................................... 8 a .5.2 - The First Oftker. ............... ......................................................... ......... IO J.5.3 Flightcrew’s 72-Hour History Prior to the Accident.. ............................. 10 1.6 Airplane information ............................................................................. ii 1.6.1 Dispatch information. ............................................................................ !I 1.6.2 Airplane Systems................................................................... ............... 12 1.6.2. I On-Board Windshear Detection System.e ................................................ 12 1.7 Meteorological information ........................................ :I. ...................... 16 1.7.1 General Weather lnfxmation .................................. ............................. 16 1.7.2 Witness Descriptions of Weather Conditions. ........................................ 19 1.7.3 Low Level Windshear Alert System (LLW.4S): ...................... .............. 21 iTiF4 - Doppler Weather Sutveiilaxe Radar (WSR-88D).................................. 26 I .7.5 Weather Radar information From CAE WSR-88D ................................ 27 1.8 Navigational Aids ............................................. .................................... 30 1.3 Communications .......... .......................................................... ............... 31 1.10 Aerodrome information. ........................................................................ 3i 1.11 Flight Recorders .................................................................................... 31 1.12 Wreckage and Impact Information........ ................................................ 33 1.12.1 Powerplants ........................................................................................... 36 1.13 Medical and Pathological Information .............. .................... ............... 37 s 1.14 Fire .................................................................................................... 37 1.15 Survival Aspects. ................................................................................... 37 c 1.15.1 USAir Passenger Manifest Procedures .................................................. 38 1.15.2 Emergency Response ............................................................................ 41 1.16 Tests and Research............................ ................................................... 43 1.16.1 Heavy Rain Effect on Airplane Performance.......................................... 43 1.16.2 Airplane Flight Profile and Event Study.. ....... ....................................... 44 1.16.3 FDRIRadar Wind Field Study................................................. ............. 46 ... 111 1.16.3 NASA Atmospheric Study of Derived Winds ........................................ 48 1.16.5 Douglas Aircraft Company Flight Simulations.. ..................................... 19 1 16.6 Control Forces During the Attempted Go-Around.. ............................... 50 1.17 USAir Organizational and Management information.. ........................... 51 l.l?.l Flight Training Department Personnel.. ..................................... ........... 51 1.17.2 Flight Safety Department ........................ ..................................... _.,,._,, 5-I i.18 Additional information ..... .................................................. .................. 54 1.18.1 USAir Training and Operating Procedures............................................. 5-l 1.18. I. 1 USAir Flightcrew Training.. .................................................................. 5-i 1.1 e. 1.2 USAir Flightcrew Training System. ......._........ _...................................... ...1. 55.~ _ -1.18.1.3 -USAir Windshear Training Program ...................................................... 55 1 .18.1 .4 Windshear Guidance Information ....................................... ................. 58 . 1.18.1 .5 USAir Operating Procedures ................................................................ SI I. 18.1 .6 USAir Crew Resource Management (CRM) Program........................... ?Y 1.18.2 FAA Oversight .................................................................................... 65 1.18.3 Pilct Decision Makim4 .......................................................................... 67 1.18.4 Sensory lilusions ................................................................. ................. 68 1,18.5 Air Traffic Control Procedures and Equipment ........................................ 70 1.I8.5.1 Dissemination of Weather information by ATC Personnel..................... 71 I .18.5.2 Charlotte ATC Tower Standard Operating Procedures ......................... 75 1.18.5.3 Charlotte ATC Tower Equipment ,. ........................................................ 76 I 18.5.4 Airport Surveillance Radar-? (ASR-9). .................................................. 77 I, 18.6 Windshear information .... ..................................................................... 80 ---- 1.18.6.1 General History.. ................................................................................... 80 1.18.6.2 Tcnninai Doppler Weather Radar (TDWK). ........................................ 85 1.13.6.3 Future Windshear Detection Equipment.. .............................................. 86 -.7 ASALYSIS 2.1 General ............................................................................................... 88 I.--77 Meteorological Factors .......................................................................... 89 -.e.311 General ... ...................................................................... ....................... 89 -.e.-777 The Environment ................................................................................. 90 -.s.773 Wind Field Analysis ............................................................ ................ 91 2.2.4 Air Traffic Control Weather Dissemination ................................... ..-..... 92 2.3 ,Aircrafi Performance. ............................................................ .............. 97 2.-i Operational Factors ............................................................................... 98 2.1.1 Flightcrew Actions ............ .............. ............ ....................................... 99 2.4.2 CRM Training. .................................................. ..i....; ............................ 103 2.4.3 Windshear Training and Airborne Weather Radar.. ............................... 106 iv --- - _- -- 2.5 FAA
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