Douglas DC-9-31 N954VJ

Summary

On 2 July 1994 at about 22:43 local time, a Douglas DC-9-31 registered N954VJ was involved in an accident near Charlotte, North Carolina, United States. 57 people were on board and 37 died, 16 were seriously injured, 4 had minor injuries. The aircraft was destroyed. The NTSB has published a probable cause for this accident; it is quoted in full below.

Date

2 July 1994 at 22:43

Classification

Accident

Location

Charlotte, North Carolina, United States

Nearest airport

Charlotte/Douglas Intl (CLT)

Coordinates

35.2309, -80.9108

Aircraft

Douglas DC-9-31

Registration

N954VJ

Category

Airplane

Engines

2

Operator

Not recorded

Operating rule

Part 121: Air Carrier

Purpose of flight

Unknown

Phase of flight

Not recorded

Route

Columbia → Unknown

Aircraft damage

Destroyed

Weather

IMC

Light

Day

NTSB number

DCA94MA065

37 people died.

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)

Quoted verbatim from the NTSB record. This site does not paraphrase or interpret it.

Read the full NTSB narrative

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.

Quoted verbatim from the NTSB record.