DCA94MA065

NTSB accident investigation · Douglas DC-9-31 · Charlotte, NC · July 2, 1994

Accident · FatalClass 1 · MajorFinal report
Date
July 2, 1994, 18:43 local (22:43 UTC)
Place
Charlotte, NC
Injuries
37 fatal, 16 serious, 4 minor
Damage
Destroyed
Phase of flight
Approach
Aircraft
N954VJDouglas DC-9-31
Weather
Instrument (IMC) · Day
Status
Completed · report January 19, 1996
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19940702017269A
Case key
10986

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

1) The flightcrew's decision to continue an approach into severe convective activity that was conducive to a microburst; 2) the flightcrew's failure to recognize a windshear situation in a timely manner; 3)the flightcrew's failure to establish and maintain the proper airplane attitude and thrust setting necessary to escape the windshear; and 4) the lack of real-time adverse weather and windshear hazard information dissemination from air traffic control, all of which led to an encounter with and the failure to escape from a microburst-induced windshear that was produced by a rapidly developing thunderstorm located at the approach end of runway 18R. Contributing to the accident were: 1) the lack of air traffic control procedures that would have required the controller to display and issue airport surveillance radar (ASR-9) weather information to the pilots of flight 1016; 2) the Charlotte tower supervisor's failure to properly advise and ensure that all controllers were aware of and reporting the reduction in visibility and runway visual range value information, and the low level windshear alerts that had occurred in multiple quadrants; 3) the inadequate remedial actions by usair to ensure adherence to standard operating procedures; and 4) the inadequate software logic in the airplane's windshear warning system that did not provide an alert upon entry into the windshear. (NTSB report AAR-95/03)

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

In flight collision with terrain/waterMissed approach (ifr)
Weather condition - microburst/wet
In-flight planning/decision - improperFlightcrewCause
Weather condition - windshear
Weather evaluation - inadequateFlightcrewCause
Aircraft handling - improperFlightcrewCause
Unsafe/hazardous condition warning - inadequateAtc personnel(lcl/gnd/clnc)Cause
Procedure inadequateFaa(other/organization)Factor
Supervision - inadequateAtc personnel(supervisor)Factor
Procedure inadequateCompany/operator managementFactor
Warning system(other) - inadequateFactor
Acft/equip,inadequate designManufacturerFactor

Analysis

The airplane collided with trees and a private residence shortly after the flightcrew executed a missed approach from the rwy 18R ILS. Flightcrew was not provided updated wx info in ATIS;wx reflected thunderstorm & rainshower. Terminal doppler wx radar not installed at arpt as scheduled; would have provided controllers with info about severity of wx, and info would have been beneficial to flightcrew. Inadeq ATC procedures, breakdown in comm in tower, prevented flightcrew from receiving additional critical info about adverse wx over arpt & along approach path. Flight encountered windshear of 61 KTS over a 15 sec period. Inadeq computer software design in the airplane's on-board windshear detection system prevented flightcrew from receiving more timely windshear alert. 1st officer initially rotated to proper 15 deg nose-up attitude during missed approach. However, thrust was set below standard go-around epr limit of 1.93, pitch attitude reduced to 5 deg nose down before flightcrew recognized dangerous situation. Faa's poi, usair's management, were aware of inconsistencies in flightcrew adherence to operating procedures within the airline; however, corrective actions had not resolved this problem.

Factual narrative

Refer to NTSB Aircraft Accident Report NTSB AAR-95-03 for detailed information.

Aircraft

Registration
N954VJ
Reported as
Douglas DC-9-31
Category
Airplane
Serial number
47590
Airframe hours
53,917
Engine
P&W JT8D-7, 12,600 lbs thrust, turbo jet
Damage
Destroyed
Fire
On-Ground
Flight
Part 121
Registered owner
Usair
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · July 1, 1994
Departed
CAE · Columbia, SC
Destination
CLT
Flight plan
IFR
Airport
CLT · Charlotte/Douglas Intl, runway 18R, 10,000 × 150 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
38
Certificates
Flight instructor, Airline transport
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Toxicology
Performed
Flight hours
8,065 total · 1,970 in this make and model

Weather

Conditions
Instrument (IMC) · Day
Wind
190° at 16 knots
Visibility
6 statute miles
Lowest ceiling
4,500 ft broken
Temperature
77 °F, dew point 66 °F
Altimeter
30.00 inHg
Observed at
CLT

Docket · 110

The files NTSB released with the investigation on October 10, 1995, on NTSB’s docket system: statements, records, photos and specialists’ reports. 137 MB in all.

Order of Hearing 1AItem 1 · .PDF · 22 KBDesignation of Hearing Officer 1BItem 2 · .PDF · 24 KBNotice of Hearing 1CItem 3 · .PDF · 44 KBDesignation of Parties to the Hearing 1DItem 4 · .PDF · 27 KBDesignation Of Chairman of Board of Inquiry 1EItem 5 · .PDF · 49 KBOperations 2A - Factual Report of Group ChairmanItem 6 · .PDF · 3.8 MBOperations 2B - Jeppesen Approach Plate-Charlotte/Douglas International AirportItem 7 · .PDF · 87 KBOperations 2C - USAir DC-9 Pilot Handbook - Weather RadarItem 8 · .PDF · 229 KBOperations 2D - USAir Flight Operations Manual-Descent & ApproachItem 9 · .PDF · 185 KBOperations 2E - USAir Pilot's Handbook - Severe PrecipitationItem 10 · .PDF · 272 KBOperations 2F - USAir Pilot's Handbook - WindshearItem 11 · .PDF · 4.7 MBOperations 2G - USAir Pilot's Handbook Missed Approach Procedure (2)Item 12 · .PDF · 155 KBOperations 2H - USAir Pilot's Handbook - GroundItem 13 · .PDF · 96 KBOperations 2I - FAA Advisory Circular AC-120-35B (19)Item 14 · .PDF · 1.3 MBOperations 2J - FAA Advisory Circular 120-59 (19)Item 15 · .PDF · 1.3 MBOperations 2K - FAA National Safety Inspection Program - USAir (20)Item 16 · .PDF · 1.1 MBOperations 2L - Pilot RecordsItem 17 · .PDF · 156 KBOperations 2M - FAA Order 1320.50 (1)Item 18 · .PDF · 130 KBOperations 2N - FAA Order 8400.10 (6)Item 19 · .PDF · 680 KBOperations 2O - Excerpts of USAir Flight Operations Training Manual (5)Item 20 · .PDF · 246 KBOperations 2P - Excerpts of USAir Check Airman Handbook (13)Item 21 · .PDF · 971 KBOperations 2Q - Excerpts of USAir Line Oriented Flight TrainingItem 22 · .PDF · 463 KBATC 3A - Factual Report of Group Chairman Air Traffic ControlItem 23 · .PDF · 1.6 MBATC 3A - Addendum #1Item 24 · .PDF · 98 KBATC 3A - Addendum #2Item 25 · .PDF · 136 KBATC 3B - Air Traffic Control TranscriptsItem 26 · .PDF · 1.7 MBATC 3C - FAA Personnel StatementItem 27 · .PDF · 190 KBATC 3C - Personnel Log For July 2, 1994Item 28 · .PDF · 356 KBATC 3D - Visibility Charts (2)Item 29 · .PDF · 83 KBATC 3E - Control Tower Layout (1)Item 30 · .PDF · 70 KBATC 3F - Daily Record of Facility OperationItem 31 · .PDF · 84 KBATC 3G - Excerpts from ATC HandbookItem 32 · .PDF · 352 KBATC 3G - Excerpts from Air Traffic Control HandbookItem 33 · .PDF · 1.6 MBATC 3H - Air Traffic BulletinsItem 34 · .PDF · 1.7 MBATC 3J - Pilot/Controller GlossaryItem 35 · .PDF · 696 KBATC 3K - Chapter 4 of CLT 7220.4Item 36 · .PDF · 195 KBATC 3L - Response LetterItem 37 · .PDF · 145 KBATC 3M - Public Hearing Transcripts (Excerpts)Item 38 · .PDF · 136 KBATC 3N - CorrespondenceItem 39 · .PDF · 328 KBATC 3O - CLT 7220.4 Change 5Item 40 · .PDF · 63 KBATC 3P - FAA ATC Accident PackageItem 41 · .PDF · 1.9 MBMeteorology 5A - Factual Report of Group ChairmanItem 42 · .PDF · 4.9 MBMeteorology 5B - Meteorological Data BItem 43 · .PDF · 794 KBMeteorology 5C - Meteorological Data CItem 44 · .PDF · 1.7 MBMeteorology 5D - WSR-88D Data From Columbia, South CarolinaItem 45 · .PDF · 1.9 MBMeteorology 5E - Low Level Wind Shear Alert System - CLTItem 46 · .PDF · 3.7 MBMeteorology 5F - Weather Radar DataItem 47 · .PDF · 1.6 MBMeteorology 5G - Calculations of Liquid Water Content, Rainfall Rate, and Percent of Water by Weight of AirItem 48 · .PDF · 574 KBMeteorology 5H - Wind Vector and Alarm Plots Low Level Windshear Alert System CLTItem 49 · .PDF · 971 KBMeteorology 5I - NASA Weather StudyItem 50 · .PDF · 1.4 MBMeteorology 5J - MIT Lincoln Laboratory CLT LLWAS StudyItem 51 · .PDF · 769 KBMeteorology 5K - MIT Lincoln Laboratory ASR-9 StudyItem 52 · .PDF · 1.7 MBSurvival Factors 6A - Factual Report of Group ChairmanItem 53 · .PDF · 2.7 MBSurvival Factors 6B - DeMary InterviewItem 54 · .PDF · 547 KBSurvival Factors 6C - Forcht InterviewItem 55 · .PDF · 195 KBSurvival Factors 6D - Markwith InterviewItem 56 · .PDF · 352 KBSurvival Factors 6E - Passenger ManifestItem 57 · .PDF · 91 KBSurvival Factors 6F - Passenger QuestionnaireItem 58 · .PDF · 970 KBSurvival Factors 6I - USAir Passenger Service ManualItem 59 · .PDF · 121 KBSurvival Factors 6J - Van Godwy PaperItem 60 · .PDF · 556 KB
All 110 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.