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Descent Below Visual Glidepath and Collision with Terrain, Delta Air

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Descent Below Visual Glidepath and Collision with Terrain, Delta Air PB97-910403 NTSB/AAR-97/03 NYC97MA005 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT DESCENT BELOW VISUAL GLIDEPATH AND COLLISION WITH TERRAIN DELTA AIR LINES FLIGHT 554 MCDONNELL DOUGLAS MD-88, N914DL LAGUARDIA AIRPORT, NEW YORK OCTOBER 19, 1996 6785B The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews. Information about available publications 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 (800)877-6799 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 NTSB/AAR-97/03 PB97-910403 NATIONAL TRANSPORTATION SAFETY BOARD WASHINGTON, D.C. 20594 AIRCRAFT ACCIDENT REPORT DESCENT BELOW VISUAL GLIDEPATH AND COLLISION WITH TERRAIN DELTA AIR LINES FLIGHT 554 MCDONNELL DOUGLAS MD-88, N914DL LAGUARDIA AIRPORT, NEW YORK OCTOBER 19, 1996 Adopted: August 25, 1997 Notation 6785B Abstract: This report explains the descent below visual glidepath and collision with terrain of Delta Air Lines flight 554 at LaGuardia Airport on October 19, 1996. The safety issues in this report focused on the possible hazards of monovision contact lenses, visual illusions encountered during the approach, non-instantaneous vertical speed information, the weather conditions encountered during the approach, the guidance in air carrier’s manuals regarding flightcrew member duties, the stabilized approach criteria in air carrier’s manuals, emergency evacuation procedures, special airport criteria and designation, and LaGuardia Airport issues/runway light spacing. Safety recommendations concerning these issues were addressed to the Federal Aviation Administration and to optometric associations. EXECUTIVE SUMMARY.........................................................................................................vii 1. FACTUAL INFORMATION.................................................................................................. 1 1.1 History of Flight ................................................................................................................... 1 1.2 Injuries to Persons ................................................................................................................ 8 1.3 Damage to Airplane.............................................................................................................. 8 1.4 Other Damage....................................................................................................................... 8 1.5 Personnel Information .......................................................................................................... 8 1.5.1 The Captain.................................................................................................................. 9 1.5.2 The First Officer......................................................................................................... 10 1.5.3 Flight Attendants........................................................................................................10 1.6 Aircraft Information............................................................................................................ 11 1.6.1 General........................................................................................................................ 11 1.6.2 Vertical Speed Information......................................................................................... 11 1.7 Meteorological Information................................................................................................ 11 1.7.1 Weather Information Provided to the Flightcrew by Delta........................................ 12 1.7.2 Runway Visual Range (RVR) Values....................................................................... 113 1.7.3 Windshear Information/Low Level Windshear Alert System (LLWAS) ................. 113 1.8 Aids to Navigation.............................................................................................................. 15 1.9 Communications................................................................................................................. 15 1.10 Airport Information .......................................................................................................... 15 1.10.1 Runway 13 Information ........................................................................................... 17 1.10.1.1 Runway 13 Runway Lights/Spacing ................................................................. 17 1.10.1.2 Runway 13 RVR Information ........................................................................... 18 1.10.1.3 Runway 13 VASI Information .......................................................................... 19 1.11 Flight Recorders ............................................................................................................... 20 1.11.1 CVR .......................................................................................................................... 20 1.11.2 FDR........................................................................................................................... 20 iii 1.11.2.1 FDR Information on Windshear........................................................................22 1.12 Wreckage and Impact Information...................................................................................23 1.13 Medical and Pathological Information.............................................................................24 1.14 Fire....................................................................................................................................24 1.15 Survival Aspects...............................................................................................................24 1.15.1 Evacuation-related Information From CVR Transcript............................................26 1.15.2 Crewmember Responsibilities During an Emergency Evacuation...........................27 1.15.2.1 Flightcrew Duties During an Emergency Evacuation.......................................27 1.15.2.2 Flight Attendant Duties During an Emergency Evacuation..............................28 1.15.3 Flight Attendant Actions/Decisionmaking During the Evacuation..........................29 1.15.3.1 Flight Attendant in Charge................................................................................29 1.15.3.2 Second Flight Attendant....................................................................................30 1.15.3.3 Third Flight Attendant.......................................................................................31 1.15.4 Delta Flight Attendant Training................................................................................31 1.15.5 Previous Safety Board Recommendation—Flight Attendants’ Actions...................31 1.16 Tests and Research...........................................................................................................32 1.17 Company/Flight Operations Information..........................................................................32 1.17.1 Delta’s Procedures and Guidance Regarding Flightcrew Responsibilities During CAT I ILS Approach to Land..............................................................................................32 1.17.1.1 First Officer’s Actions During Approach to Land............................................36 1.17.1.2 Delta’s Postaccident Actions Regarding PF/PNF Duties..................................36 1.17.2 Stabilized Approach Criteria.....................................................................................37 1.17.2.1 Previous Safety Board/FAA Actions Regarding Stabilized Approaches..........39 1.17.2.2 Delta’s Actions Regarding Stabilized Approaches...........................................41 1.17.3 Crew Resource Management (CRM) Training........................................................42 1.18 Additional Information....................................................................................................43 1.18.1 FAA Oversight of Airman Medical Certification (Vision)......................................43 iv 1.18.1.1 Vision Requirements for Certification .............................................................. 44 1.18.1.2 Information/Guidance Available to AMEs and Optometrists........................... 46 1.18.2 Information on Monovision (MV) Contact Lenses.................................................. 47 1.18.2.1 The Captain’s Use of Monovision Contact Lenses........................................... 48 1.18.2.2 Captain’s Postaccident Vision Test Results...................................................... 49 1.18.2.3 General Aviation Accident Involving Monovision Contact Lenses.................. 50 1.18.2.4
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