DCA99MA060

NTSB accident investigation · McDonnell Douglas MD-82 · Little Rock, AR · June 2, 1999

Accident · FatalClass 1 · MajorFinal report
Date
June 1, 1999, 23:51 local (Jun 2, 1999, 04:51 UTC)
Place
Little Rock, AR
Injuries
11 fatal, 45 serious, 65 minor, 24 uninjured
Damage
Destroyed
Phase of flight
Landing
Aircraft
N215AAMcDonnell Douglas MD-82
Weather
Instrument (IMC) · Night
Status
Completed · report May 28, 2002
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Safety recommendations
Yes
FAA report
19990601005919A
Case key
46532

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

The flight crew's failure to discontinue the approach when severe thunderstorms and their associated hazards to flight operations had moved into the airport area and the crew's failure to ensure that the spoilers had extended after touchdown.

Contributing to the accident were the flight crew's (1) impaired performance resulting from fatigue and the situational stress associated with the intent to land under the circumstances, (2) continuation of the approach to a landing when the company's maximum crosswind component was exceeded, and (3) use of reverse thrust greater than 1.3 engine pressure ratio after landing.

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.

Loss of control - on ground/waterLanding - roll
FatigueFlightcrewFactor
Flight into known adverse weather - continuedFlightcrewCause
Improper decisionFlightcrewCause
Improper use of procedureFlightcrewFactor
Procedures/directives - not complied withFlightcrewFactor
OverrunLanding - roll
Spoiler extension - not verifiedFlightcrewCause
Improper use of equipment/aircraftFlightcrewFactor
Reversers - excessiveFlightcrewFactor
On ground/water collision with objectLanding - roll
Object - approach light/navaidFactor

Analysis

The full report (NTSB/AAR-01-02) is available on the NTSB Web site. See http://www.ntsb.gov/Publictn/publictn.htm for details.

On June 1, 1999, at 2350:44 central daylight time,1 American Airlines flight 1420, a McDonnell Douglas DC-9-82 (MD-82), N215AA, crashed after it overran the end of runway 4R during landing at Little Rock National Airport in Little Rock, Arkansas. Flight 1420 departed from Dallas/Fort Worth International Airport, Texas, about 2240 with 2 flight crewmembers, 4 flight attendants, and 139 passengers aboard and touched down in Little Rock at 2350:20. After departing the end of the runway, the airplane struck several tubes extending outward from the left edge of the instrument landing system (ILS) localizer array, located 411 feet beyond the end of the runway; passed through a chain link security fence and over a rock embankment to a flood plain, located approximately 15 feet below the runway elevation; and collided with the structure supporting the runway 22L approach lighting system. The captain and 10 passengers were killed; the first officer, the flight attendants, and 105 passengers received serious or minor injuries; and 24 passengers were not injured.2 The airplane was destroyed by impact forces and a postcrash fire. Flight 1420 was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules (IFR) flight plan.

Factual narrative

The full report (NTSB/AAR-01-02) is available on the NTSB Web site. See http://www.ntsb.gov/Publictn/publictn.htm for details.

History of Flight

On June 1, 1999, about 2350:44 central daylight time, American Airlines flight 1420, a McDonnell Douglas DC-9-82 (MD-82), N215AA, crashed after it overran the end of runway 4R during landing at Little Rock National Airport in Little Rock, Arkansas. Flight 1420 departed from Dallas/Fort Worth International Airport, Texas, about 2240 with 2 flight crewmembers, 4 flight attendants, and 139 passengers aboard and touched down in Little Rock about 2350:20. After departing the end of the runway, the airplane struck several tubes extending outward from the left edge of the instrument landing system (ILS) localizer array, located 411 feet beyond the end of the runway; passed through a chain link security fence; went down a rock embankment to a flood plain, located approximately 15 feet below the runway elevation; and collided with the structure supporting the runway 22L approach lighting system. The captain and 10 passengers were killed; the first officer, the flight attendants, and 105 passengers received serious or minor injuries; and 24 passengers were not injured. The airplane was destroyed by impact forces and a postcrash fire. Flight 1420 was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 121 on an instrument flight rules (IFR) flight plan.

Flight 1420 was the third and final leg of the first day of a 3-day sequence for the flight crew. The flight sequence began at O'Hare International Airport, Chicago, Illinois. According to American Airlines company records, the captain checked in for the flight at 1038, and the first officer checked in at 1018. Flight 1226, from Chicago to Salt Lake City International Airport, Utah, departed about 1143 and arrived about 1458 (1358 mountain daylight time). Flight 2080, from Salt Lake City to Dallas/Fort Worth, departed about 1647 (1547 mountain daylight time) and arrived about 2010, 39 minutes later than scheduled because of an airborne hold during the approach resulting from adverse weather in the airport area. The captain was the flying pilot for flight 1226, and the first officer was the flying pilot for flight 2080.

Flight 1420, from Dallas/Fort Worth to Little Rock, was scheduled to depart at 2028 and arrive at 2141. However, before its arrival at Dallas/Fort Worth, the flight crew received an aircraft communication addressing and reporting system (ACARS) message indicating a delayed departure time of 2100 for flight 1420. After deplaning from flight 2080, the flight crew proceeded to the departure gate for flight 1420. The flight crew then received trip paperwork for the flight, which included an American Airlines weather advisory for a widely scattered area of thunderstorms along the planned route and two National Weather Service (NWS) in-flight weather advisories for an area of severe thunderstorms along the planned route.

The airplane originally intended to be used for the flight was delayed in its arrival to Dallas/Fort Worth because of the adverse weather in the area. After 2100, the first officer notified gate agents that flight 1420 would need to depart by 2316 because of American's company duty time limitation. The first officer then telephoned the flight dispatcher to suggest that he get another airplane for the flight or cancel it. Afterward, the accident airplane, N215AA, was substituted for flight 1420. The flight's 2240 departure time was 2 hours 12 minutes later than the scheduled departure time. The captain was the flying pilot, and the first officer was the nonflying pilot.

About 2254, the flight dispatcher sent the flight crew an ACARS message indicating that the weather around Little Rock might be a factor during the arrival. The dispatcher suggested that the flight crew expedite the arrival to beat the thunderstorms if possible, and the flight crew acknowledged this message. The first officer indicated, in a postaccident interview, that "there was no discussion of delaying or diverting the landing" because of the weather. According to the predeparture trip paperwork, two alternate airports-Nashville International Airport, Tennessee, and Dallas/Fort Worth-were specified as options in case a diversion was needed.

Beginning about 2258, flight 1420 was handled by controllers from the Fort Worth Air Route Traffic Control Center (ARTCC). About 2304, the Fort Worth center broadcast NWS Convective SIGMET [significant meteorological information] weather advisory 15C for an area of severe thunderstorms that included the Little Rock airport area. The cockpit voice recorder (CVR) indicated that the flight crew had discussed the weather and the need to expedite the approach. About 2325:47, the captain stated, "we got to get over there quick." About 5 seconds later, the first officer said, "I don't like that that's lightning," to which the captain replied, "sure is." The CVR also indicated that the flight crew had the city of Little Rock and the airport area in sight by about 2326:59.

About 2327, the Fort Worth center cleared the flight to descend to 10,000 feet mean sea level (msl) and provided an altimeter setting of 29.86 inches of mercury (Hg). The flight was transferred about 2328 to the Memphis ARTCC, which provided the same altimeter setting.

According to the CVR, the flight crew contacted the Little Rock Air Traffic Control Tower (ATCT) about 2334:05. The controller advised the flight crew that a thunderstorm located northwest of the airport was moving through the area and that the wind was 280 degrees at 28 knots gusting to 44 knots. The first officer told the controller that he and the captain could see the lightning. The controller told the flight crew to expect an ILS approach to runway 22L. The first officer indicated in a postaccident interview that, during the descent into the terminal area, the weather appeared to be about 15 miles away from the airport and that he and the captain thought that there was "some time" to make the approach.

The CVR indicated that, between about 2336:04 and about 2336:13, the captain and first officer discussed American Airlines' crosswind limitation for landing. The captain indicated that 30 knots was the crosswind limitation but realized that he had provided the limitation for a dry runway. The captain then stated that the wet runway crosswind limitation was 20 knots, but the first officer stated that the limitation was 25 knots. In testimony at the Safety Board's public hearing on this accident, the first officer stated that neither he nor the captain checked the actual crosswind limitation in American's flight manual. The first officer testified that he had taken the manual out but that the captain had signaled him to put the manual away because the captain was confident that the crosswind limitation was 20 knots.

About 2339:00, the controller cleared the flight to descend to an altitude of 3,000 feet msl. The controller then asked the flight crew about the weather conditions along the runway 22L final approach course, stating his belief that the airplane's weather radar was "a lot better" than the weather radar depiction available in the tower. About 2339:12, the first officer stated, "okay, we can see the airport from here. We can barely make it out but we should be able to make [runway] two two that storm is moving this way like your radar says but it is a little bit farther off than you thought." The controller then offered flight 1420 a visual approach to the runway, but the first officer indicated, "at this point, we really can't make it out. We're gonna have to stay with you as long as possible."

About 2339:45, the controller notified flight 1420 of a windshear alert, reporting that the centerfield wind was 340 degreesat 10 knots, the north boundary wind was 330 degrees at 25 knots, and the northwest boundary wind was 010 d

Aircraft

Registration
N215AA
Reported as
McDonnell Douglas MD-82
Category
Airplane
Serial number
49163
Airframe hours
449,136
Engines
P&W JT8D-217C, turbo fanP&W JT8D-217C, turbo fan
Damage
Destroyed
Fire
On-Ground
Flight
Part 121
Registered owner
American Airlines Inc
Airworthiness certificate
Standard, Transport
Last inspection
Unknown · May 31, 1999
Departed
Dfw, TX
Destination
Little Rock, AR
Flight plan
Unknown
Airport
LIT · Adams Field, runway 4R, 7,200 × 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 · 2

As NTSB recorded them. NTSB leaves out names.

Role
Pilot
Age
48
Injuries
Fatal
Certificate
Airline transport
Airplane ratings
Multi-engine land
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Left
Flight hours
10,234 total · 7,384 as pilot in command · 54 in the last 90 days · 14 in the last 30 days
Role
Co-pilot
Age
35
Injuries
Serious
Certificate
Airline transport
Airplane ratings
Multi-engine land
Medical
Class 1, Valid Medical--no waivers/lim.
Seat
Right
Flight hours
4,292 total · 182 in this make and model · 176 in the last 90 days · 65 in the last 30 days

Weather

Conditions
Instrument (IMC) · Night
Wind
280° at 18 knots, gusting 26
Visibility
1 statute miles
Lowest ceiling
5,000 ft overcast
Temperature
66 °F, dew point 63 °F
Altimeter
29.89 inHg

Docket · 316

The files NTSB released with the investigation on January 27, 2000, on NTSB’s docket system: statements, records, photos and specialists’ reports.

Operations 2-exhibit no 2A-group chairman factual reportItem 1 · PDF · 29 pages · 474 KBOperations 2-exhibit no 2B-attachment 1-interview summariesItem 2 · PDF · 18 pages · 133 KBOperations 2-exhibit no 2C-attachment 2-transcripts of dfw and lax field interviewsItem 3 · PDF · 3 pages · 34 KBOperations 2-exhibit no 2D-attachment 3-flight time limitations-allied pilots contractItem 4 · PDF · 4 pages · 83 KBOperations 2-exhibit no 2E-attachment 4-flight 1420 departure papersItem 5 · PDF · 34 pages · 2.8 MBOperations 2-exhibit no 2F-attachment 5-AA wind component chartItem 6 · PDF · 3 pages · 142 KBOperations 2-exhibit no 2G-attachment 6-adams airport little rock Arkansas aa jeppesen chartsItem 7 · PDF · 5 pages · 282 KBOperations 2-exhibit no 2H-attachment 7-AA-techniques-descriptionItem 8 · PDF · 3 pages · 30 KBOperations 2-exhibit no 2I-attachment 8-acars message to flight 1420 crewItem 9 · PDF · 3 pages · 109 KBOperations 2-exhibit no 2J-attachment 9-approach briefing requirement-aa flight manualItem 10 · PDF · 3 pages · 26 KBOperations 2-exhibit no 2K-attachment 10-approach briefing requirement-aa DC-9 operating manualItem 11 · PDF · 3 pages · 33 KBOperations 2-exhibit no 2L-attachment 11-depiction of aa mechanical checklistItem 12 · PDF · 3 pages · 113 KBOperations 2-exhibit no 2M-attachment 12-AA before landing checklist instructionsItem 13 · PDF · 3 pages · 37 KBOperations 2-exhibit no 2N-attachment 13-detailed aa before landing checklistItem 14 · PDF · 3 pages · 42 KBOperations 2-exhibit no 2O-attachment 14-AA instructor-check airman guide instructions for before landing checkliItem 15 · PDF · 3 pages · 37 KBOperations 2-exhibit no 2P-attachment 15-little rock ATIS from ATC transcriptItem 16 · PDF · 3 pages · 91 KBOperations 2-exhibit no 2Q-attachment 16-AA DC-9 operating manual stabilized approach conceptItem 17 · PDF · 3 pages · 21 KBOperations 2-exhibit no 2R-attachment 17-AA MD-80 standard callouts-all descents approaches and landingsItem 18 · PDF · 3 pages · 50 KBOperations 2-exhibit no 2S-attachment 18-AA weather deterioration guidanceItem 19 · PDF · 3 pages · 32 KBOperations 2-exhibit no 2T-attachment 19-AA flap extension procedureItem 20 · PDF · 3 pages · 34 KBOperations 2-exhibit no 2U-attachment 20-AA DC-9 operating manual requirements to continue appraoch below da-dhItem 21 · PDF · 3 pages · 33 KBOperations 2-exhibit no 2V-attachment 21-AA flight manual requirements to continue approach below da-dh dated 4-1Item 22 · PDF · 2 pages · 27 KBOperations 2-exhibit no 2W-attachment 22-AA flight manual requirements to continue approach below da-dh dated 8-1Item 23 · PDF · 3 pages · 38 KBOperations 2-exhibit no 2X-attachment 23-AA wind landing limitsItem 24 · PDF · 3 pages · 65 KBOperations 2-exhibit no 2Y-attachment 24-AA wet runway conditions-landingItem 25 · PDF · 3 pages · 29 KBOperations 2-exhibit no 2Z-attachment 25-AA requirements for category 1 ILS approachItem 26 · PDF · 3 pages · 50 KBOperations 2-exhibit no 2AA-attachment 26-AA windshear guidanceItem 27 · PDF · 3 pages · 32 KBOperations 2-exhibit no 2BB-attachment 27-AA landing windshear guidanceItem 28 · PDF · 3 pages · 34 KBOperations 2-exhibit no 2CC-attachment 28-AA category 1 ils-crew coordination proceduresItem 29 · PDF · 3 pages · 124 KBOperations 2-exhibit no 2DD-attachment 29-AA automatic brakes descriptionItem 30 · PDF · 3 pages · 32 KBOperations 2-exhibit no 2EE-attachment 30-AA directional control with reverse thrust guidanceItem 31 · PDF · 3 pages · 26 KBOperations 2-exhibit no 2FF-attachment 31-AA auto brakes guidanceItem 32 · PDF · 3 pages · 23 KBOperations 2-exhibit no 2GG-attachment 32-AA landing under adverse weather guidanceItem 33 · PDF · 3 pages · 33 KBOperations 2-exhibit no 2HH-attachment 33-AA landing guidance for spoiler leverItem 34 · PDF · 3 pages · 32 KBOperations 2-exhibit no 2II-attachment 34-Boeing MD-80 wet runway reverse thrust guidanceItem 35 · PDF · 3 pages · 34 KBOperations 2-exhibit no 2JJ-attachment 35-mconnell douglas-boeing all operators letterItem 36 · PDF · 6 pages · 136 KBOperations 2-exhibit no 2KK-attachment 36-AA wet-slippery runway-crosswind guidanceItem 37 · PDF · 3 pages · 33 KBOperations 2-exhibit no 2LL-attachment 37-AA takeoff and landing simulator training sessionItem 38 · PDF · 3 pages · 30 KBOperations 2-exhibit no 2MM-attachment 38-AA DC-9 operating manual guidance for landing on wet-slippery runwaysItem 39 · PDF · 3 pages · 39 KBOperations 2-exhibit no 2NN- attachment 39-FAA order 840010 guidance for apd designees certificationItem 40 · PDF · 4 pages · 105 KBOperations 2-exhibit no 2OO-attachment 40-FAA order 840010 guidance for check airmen certificationItem 41 · PDF · 5 pages · 105 KBOperations 2-exhibit no 2PP-attachment 41-AA weather guidanceItem 42 · PDF · 3 pages · 33 KBOperations 2-exhibit no 2QQ-attachment 42-AA takeoff and landing simulator training observation by captain randyItem 43 · PDF · 5 pages · 52 KBOperations 2-exhibit no 2RR- attachment 43-AA takeoff and landing simulator training observation by captain daveItem 44 · PDF · 3 pages · 20 KBOperations 2-exhibit no 2SS-attachment 44-AA low level windshear alert systems informationItem 45 · PDF · 3 pages · 28 KBOperations 2-addendum to factual report of group chairmanItem 46 · PDF · 1 page · 22 KBOperations 2-errata-addendum to group chairman's factual reportItem 47 · PDF · 1 page · 28 KBATC 3-exhibit no 3A-group chairman factual reportItem 48 · PDF · 10 pages · 178 KBATC 3-exhibit no 3B-little rock tower air traffic contrtol transcriptItem 49 · PDF · 18 pages · 205 KBATC 3-LIT ATCT briefingsItem 50 · PDF · 8 pages · 331 KBATC 3-AAL1420 stripItem 51 · PDF · 1 page · 74 KBATC 3-arts iie time settingItem 52 · PDF · 2 pages · 64 KBATC 3-siso logs 7230-10Item 53 · PDF · 4 pages · 177 KBATC 3-RWY selection SOPItem 54 · PDF · 2 pages · 175 KBATC 3-daily rec facil opsItem 55 · PDF · 2 pages · 58 KBATC 3-controller stmtsItem 56 · PDF · 2 pages · 188 KBATC 3-recorded llwas dataItem 57 · PDF · 1 page · 111 KBATC 3-RVR-RWY lt archiveItem 58 · PDF · 1 page · 81 KBATC 3-memphis tmu logItem 59 · PDF · 1 page · 81 KBATC 3-power recordsItem 60 · PDF · 4 pages · 108 KB
All 316 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.