NTSB CAROL · Event
Event DCA94MA065
Aircraft involved
Probable cause & findings
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)
Factual narrative
Refer to NTSB Aircraft Accident Report NTSB AAR-95-03 for detailed information. 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. Source: NTSB Aviation Accident Database (Pre-2008 Archive) Retrieved: 2026-02-12
Verbatim from NTSB's published report. Source file
NTSB_1994_DCA94MA065.txt.
Findings + structured fields enriched from FAA avall.mdb.
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Related research
What the literature says.
Academic papers and agency reports matching this event's aircraft type or causal vocabulary (stall, go-around, thunderstorm, microburst). Sourced from NASA NTRS, NTSB Safety Studies, FAA CAMI, AOPA Air Safety Institute, Embry-Riddle Scholarly Commons, arXiv, and the Semantic Scholar academic graph.
- NASA NTRS 2019 · Conference Paper
Optimal recovery from microburst wind shear
The flight path of a twin-jet transport aircraft is optimized in a microburst encounter during approach to landing. The objective is to execute an escape maneuver that maintains safe ground clearance …
- NASA NTRS 2019 · Contractor Report (CR)
An Examination of Aviation Accidents Associated with Turbulence, Wind Shear and Thunderstorm
The focal point of the study reported here was the definition and examination of turbulence, wind shear and thunderstorm in relation to aviation accidents.
- NASA NTRS 2019 · Conference Paper
Analysis of aircraft control strategies for microburst encounter
Analyses have indicated that improved control strategies could reduce the threat posed by the presence of microburst-type wind shear during aircraft takeoffs and landings.
- NASA NTRS 2026 · Conference Paper
Computational Analysis of Steady State Aerodynamics of Transonic Truss-Braced Wing Configuration in Deep Stall
This study presents a computational investigation of steady state aerodynamics of the Subsonic Ultra-Green Aircraft Research (SUGAR) Transonic Truss-Braced Wing (TTBW) configuration over a wide range …
- NASA NTRS 2025 · Conference Paper
A Training Study to Improve Monitoring During A Go-Around
As part of an FAA program to improve go-around (GA) safety, we were asked to determine if we could improve the performance of the Pilot Monitoring (PM) during a GA maneuver.
- Flight Safety Foundation 2024 · FSF / AeroSafety World
Go-Around Safety Forum Findings
Foundation Go-Around Safety Forum technical findings — examines why pilots fail to execute go-arounds when criteria are met (stabilized approach gate not met, energy state out of envelope, traffic con…
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