Transcription of NATIONAL TRANSPORTATION SAFETY BOARD
1 NATIONALTRANSPORTATIONSAFETY BOARDWASHINGTON, 20594 AIRCRAFT ACCIDENT REPORTPB2001-910402 NTSB/AAR-01/02 DCA99MA060 RUNWAY OVERRUN DURING LANDINGAMERICAN AIRLINES FLIGHT 1420 MCDONNELL DOUGLAS MD-82, N215 AALITTLE ROCK, ARKANSASJUNE 1, 19997195 AAircraft Accident ReportRunway Overrun During LandingAmerican Airlines Flight 1420 McDonnell Douglas MD-82, N215 AALittle Rock, ArkansasJune 1, 1999 NTSB/AAR-01/02PB2001-910402 NATIONAL TRANSPORTATION SAFETY BoardNotation 7195A490 L Enfant Plaza, October 23, 2001 Washington, 20594E PLURIBUS UNUM NATIONAL TRASPORTATION BOARDSAFETYNN ational TRANSPORTATION SAFETY BOARD . 2001. Runway Overrun During landing , American AirlinesFlight 1420, McDonnell Douglas MD-82, N215AA, Little Rock, Arkansas, June 1, 1999.
2 AircraftAccident Report NTSB/AAR-01/02. Washington, : This report explains the accident involving American Airlines flight 1420, a McDonnellDouglas MD-82, which crashed after it overran the end of runway 4R during landing at Little RockNational Airport in Little Rock, Arkansas. SAFETY issues discussed in this report focus on flight crewperformance, flight crew decision-making regarding operations in adverse weather, pilot fatigue, weatherinformation dissemination, emergency response, frangibility of airport structures, and Federal AviationAdministration (FAA) oversight. SAFETY recommendations concerning these issues are addressed to theFAA and the NATIONAL Weather NATIONAL TRANSPORTATION SAFETY BOARD is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,pipeline, and hazardous materials SAFETY .
3 Established in 1967, the agency is mandated by Congress through the Independent SAFETY BoardAct of 1974 to investigate TRANSPORTATION accidents, determine the probable causes of the accidents, issue SAFETY recommendations, studytransportation SAFETY issues, and evaluate the SAFETY effectiveness of government agencies involved in TRANSPORTATION . The SAFETY Boardmakes public its actions and decisions through accident reports, SAFETY studies, special investigation reports, SAFETY recommendations, andstatistical publications are available in their entirety on the Web at < >. Other information about available publications alsomay be obtained from the Web site or by contacting: NATIONAL TRANSPORTATION SAFETY BoardPublic Inquiries Section, RE-51490 L Enfant Plaza, , 20594(800) 877-6799 or (202) 314-6551 SAFETY BOARD publications may be purchased, by individual copy or by subscription, from the NATIONAL Technical Information Service.
4 Topurchase this publica tion, order report number PB2001-910402 from: NATIONAL Technical Information Service5285 Port Royal RoadSpringfield, Virginia 22161(800) 553-6847 or (703) 605-6000 The Independent SAFETY BOARD Act, as codified at 49 Section 1154(b), precludes the admission into evidence or use of BOARD reportsrelated to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. iiiAircraft Accident ReportContentsAbbreviations .. ixExecutive Summary .. xii1. Factual Information .. History of Flight .. Injuries to Persons.. Damage to Airplane .. Other Damage .. Personnel Information.. Captain .. First Officer.. Flight Attendants.. Airplane Information .. Records.
5 System Information .. on Spoiler System Operation .. Spoiler Events .. System Information .. and Balance .. s Previous Flights on the Day of the Accident.. Demonstrated landing Distance .. Meteorological Information .. Weather Information .. Weather Service Information .. Airlines Weather Information .. Weather Information .. Data .. Statements .. Hazard Study .. Aids to Navigation .. Communications .. Airport Information.. Runway 4R/22L SAFETY Areas .. Runway 22L Approach Lighting System Support Structure .. Runway 4R Assessments .. Tire Marks .. Runway Surface Information .. Air Traffic Control Tower Information .. Flight Recorders .. Cockpit Voice Recorder.. Flight Data Recorder.
6 Wreckage and Impact Information .. General Wreckage Description .. 43 ContentsivAircraft Accident Spoiler System .. Engines.. landing Gear and Brake Assemblies.. Medical and Pathological Information .. Fire .. Survival Aspects .. General .. Evacuation of Passengers and Crewmembers .. Emergency Response .. Passenger Statements .. Tests and Research .. Spoiler System Ground Tests.. Testing Conducted After the Palm Springs Incident .. Main landing Gear Tire Examination .. Cockpit Voice Recorder Sound Spectrum Study .. Airplane Performance Study .. Calculated Ground Trajectory .. Ground Deceleration Study .. Engineered Materials Arresting System Computer Model .. Organizational and Management Information.
7 Aviation SAFETY Action Program .. Flight Crew Training .. Simulator Flight Training .. Observations of Simulator Sessions.. Human Factors and SAFETY Training .. Approach Procedures .. Approach Briefing .. Before landing Checklist .. Manufacturer s Information .. Crew Coordination Procedures .. Stabilized Approach Concept .. Federal Aviation Administration Guidance .. Thunderstorm and Windshear Avoidance .. Continuation of an Approach Below the Decision Height .. Missed Approach Policy .. landing Procedures .. Wind landing Limits .. Manufacturer s Information .. Spoiler Deployment Procedures .. Manufacturer s Information .. Braking Procedures .. Manufacturer s Information.
8 Use of Reverse Thrust .. Manufacturer s Information .. MD-80 All Operators Letter .. Postaccident Actions .. DC-9 Operating Manual Changes .. Flight Manual Changes .. Federal Aviation Administration Oversight.. Principal Operations Inspector.. 90 ContentsvAircraft Accident Aircrew Program Manager .. Additional Information .. Runway Friction Information.. Study on Thunderstorm Penetration in the Terminal Area .. Studies on Flight Crew Decision-Making .. SAFETY BOARD Study of Flight Crew Involvement in Major Accidents.. NATIONAL Aeronautics and Space Administration Study on Flight CrewDecision Errors .. Technologies to Detect and Locate Downed Airplanes.. Previous Weather-Related Accidents.
9 Previous Weather-Related SAFETY Recommendations .. Previous Fatigue-Related Accidents .. Previous Fatigue-Related SAFETY Recommendation.. Additional Fatigue Information .. Other Previous Related Accidents .. Accidents Involving Rescue Efforts .. Accidents Involving Delayed Emergency Response .. Other Previous Related SAFETY Recommendations .. Aircraft Operations in the Airport Environment .. Stabilized Approach Guidance .. Manufacturer s Operating Information .. 1112. Analysis .. General .. Accident Scenario .. Approach.. Into the Terminal Area .. to the Airport for Final Approach .. Final Approach Segment.. of the Flight Crew s Performance During the Approach .. landing .. of Spoiler Deployment.
10 Arming.. Design Regarding Spoiler Arming .. Spoiler Deployment .. of Reverse Thrust Above Engine Pressure Ratio .. of Manual Braking .. of the landing .. Factors .. Role of Situational Stress .. Standards and Practices.. Role of Fatigue .. Meteorological Support .. Information Provided by the Local Controller .. Information Depiction on Air Traffic Control Radar Systems .. En Route Weather Information .. Office Weather Radar .. Weather Service Unit Staffing .. Surface Observing System Lockout Period .. Weather Equipment.. 150 ContentsviAircraft Accident Visual Range System.. Level Windshear Alert System .. Emergency Response .. Rescue and Fire Fighting Staffing Levels .. Detection and Location Technology.
