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  3. NTSB A-21-002
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NTSB · Safety Recommendation

Safety Recommendation A-21-002

Recommendation

TO THE NATIONAL WEATHER SERVICE: Revise National Weather Service Instruction 30-2112 to provide operational (forecasting) staff at weather forecast offices the authority to determine whether report processing for an automated surface observing system sensor at an unattended site (or other site not currently being appropriately augmented) should be turned off immediately if the sensor is believed to be reporting erroneously but does not yield flags in its maintenance monitoring data and to include clear instructions for performing this task.

Safety Issue and Context

These recommendations derive from the NTSB’s investigation of a fatal accident involving a privately operated Cirrus SR22 that crashed while maneuvering at low altitude near Ely, Nevada, on February 15, 2019, as well as our investigation of the sinking of the amphibious passenger vessel Stretch Duck 7 on July 19, 2018, near Branson, Missouri. The NTSB is issuing two new safety recommendations to the NWS and two new recommendations to the FAA to address identified safety issues.

Response History

July 6, 2023 · NTSB Correspondence · United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service

We note that you are working with the FAA to update NWS Instruction 30-2112, as recommended. We also note that, in the meantime, you plan to tell operational forecasting staff how to request that the ASOS Monitoring Center turn off any erroneous sensors. Pending our review of the revised policy, Safety Recommendation A-21-2 remains classified OPEN-- ACCEPTABLE RESPONSE.

October 26, 2022 · Recipient Response · United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service

From John D. Murphy, Chief Operating Officer, NOAA National Weather Service: NWS Instruction 30-2112 will be updated to address the issue. In the interim, a Maintenance Note will be issued informing the operational staff (forecasting) of a process where they can contact the AOMC and have them turn off any erroneous sensors.

August 24, 2021 · NTSB Correspondence · United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service

We note that, in coordination with the Federal Aviation Administration, you are currently reviewing NWS policies to determine how to best incorporate the recommended changes. Pending our review of the revised policies, Safety Recommendations A-21-1 and -2 are classified OPEN-- ACCEPTABLE RESPONSE.

Please update us at ExecutiveSecretariat@ntsb.gov on your progress toward implementing these recommendations, and do not submit both an electronic and a hard copy of the same response.

March 23, 2021 · Recipient Response · United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service

-From John D. Murphy, Chief Operating Officer, NOAA National Weather Service: The NWS acknowledges receipt of these two NTSB Safety Recommendations, and we are reviewing our policy in light of these recommendations. Policy updates will be made in coordination with the FAA over the next few months. We will provide additional updates as the work progresses and is completed.

The NWS point of contact, NWS Forensic Services Program Manager Lora Wilson, will be responsible for the coordination and consolidation of future responses for these recommendations. Please have your staff contact Ms. Wilson.

February 11, 2021 · NTSB Correspondence · United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters.

The attached letter from the NTSB Chairman provides information about the NTSB’s February 1, 2021, report Revise Processes, Procedures, and Reporting Capabilities for Automated Weather Systems, NTSB/ASR-21/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. For more information about NTSB and our recommendation process, please see the attached one-page summary.

The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (for example, A-21-1 and -2). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply exceeds 20 megabytes, including attachments, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.

All communications regarding safety recommendations will be stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this/these recommendation(s). Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov.

The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to assist victims and their family members affected by major transportation disasters.

Read Recommendation

Recommendation Facts

Status
Open - Acceptable Response
Issued
February 11, 2021
Priority
CLASS II
Recipient
United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Adopted
February 1, 2021
Related Investigation
WPR19FA084
Related Report
ASR-21-01

We are providing the following information to urge the National Weather Service (NWS) to act on the safety recommendations in this letter because we believe your organization can help reduce the risk of future accidents. For more information about the NTSB and our recommendation process, please see the attached one-page summary.

This letter also includes information about our February 1, 2021, report Revise Processes, Procedures, and Reporting Capabilities for Automated Weather Systems, NTSB/ASR-21/01. The details of this investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. As a result of our investigation, we identified the following safety issues:

• Lack of clarity in guidance concerning definitions and procedures intended to support timely automated surface observing systems (ASOS) maintenance • Lack of consistent criteria for issuing ASOS- and automated weather observing (AWOS) related notices to airmen • Ineffective maintenance procedures intended to mitigate internal clock drift and resulting erroneous timestamping of observations on some non-federal AWOSs

Accordingly, the NTSB makes the following safety recommendations to the NWS:

• Revise National Weather Service Instruction 30-2111 to clearly define “outage,” “failure,” and similar terms regarding individual automated surface observing system (ASOS) sensor and component performance and to include explicit maintenance actions intended to mitigate presumed erroneous ASOS sensor reporting that does not generate failure flags in maintenance monitoring data. (A 21-1)

• Revise National Weather Service Instruction 30-2112 to provide operational (forecasting) staff at weather forecast offices the authority to determine whether report processing for an automated surface observing system sensor at an unattended site (or other site not currently being appropriately augmented) should be turned off immediately if the sensor is believed to be reporting erroneously but does not yield flags in its maintenance monitoring data and to include clear instructions for performing this task. (A-21-2) The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives.

We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (Safety Recommendations A-21-1 and -2). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov. If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.

All communications regarding safety recommendations are stored by the NTSB and viewable by the public. Please do not send privileged or confidential communications in response to this/these recommendation(s). Responses marked as confidential or privileged (or similar designations) will be considered nonresponsive. In the likely event that your company uses auto generated and/or preformatted confidentiality statements on letterhead or outgoing e-mails, please include a statement in your letter indicating that the information can be publicly released. If you have concerns about this protocol, please contact us at ExecutiveSecretariat@ntsb.gov.