2. Accident Overview
June 1, 1999. 2350:44 AA Flight #1420 KDFW-KLIT Runway 4R
McDonnell Douglas DC-9-82 (MD-82) N215AA
145 Souls
Scheduled 2028-2141
Departure Delayed to 2240 (2 hours 12 minutes late)
Time Pressure
KDFW & KBNA diversion options (FO quote)
Received Warnings
Weather Advisory – WDLY SCTD TSTMS
Two NWS in-flight weather advisories SVR TSTMS
3. Accident Overview
• 2254 – ACARS message received, weather in Little Rock possible factor.
• Dispatcher suggestion, expedite!
• 2258 – 1420 handed off to Fort Worth ARTCC
• 2304 – Fort Worth center issued NWS Convective SIGMET
• 2325 – CAM1 “we got to get over there quick.”
• 2326 – Crew reported Little Rock in sight
• 2327 – Center cleared flight to descend to 100
• 2328 – Flight 1420 was transferred to Memphis ARTCC
• 2334 – Flight 1420 contacted KLIT tower
• Controller advised crew about Thunderstorm
• 2336 – Crosswind Discussion
• Crosswind limitation
4. Accident Overview
2339 – KLIT tower cleared 1420 to descend to 030
Aircraft radar vs KLIT tower’s radar, 22L
2339:45 – KLIT tower advised 1420 of windshear
Change to 4R
2340:20 – Vectored to 4R, turned away from airport
2342:19-24 – CAM1 “do you have the airport? Is that it right there? I don’t see a runway”
2342:27 – second thunderstorm moving through, 340o at 16 kts
2342:40 – short approach, CAM1 “yeah, if you see the runway. ‘cause I don’t quite see it.” CAM2
“yeah it’s right here, see it?” CAM1 “you just point me in the right direction and I’ll start slowing
down here.”
2342:55 – CAM2 “it’s going over the field.”
2343:11 – Cleared for visual 4R
5. Accident Overview
2343:35-38 – CAM1 – lost visual while FO tried to assist
2343:59 – Cleared to land visual 4R, winds 330o at 21 kts
2344:30 – CAM2 stated they lost visual with airport
Vectors for ILS 4R
2345:47 – CAM2 “we’re getting pretty close to this storm. We’ll keep it tight if we have to.”
2346:39 – aircraft 3 miles from OM
2346:52 – “we’re going right into this”
2347:08 – 1420 cleared to land ILS 4R, winds 350o at 30kts to 45 kts
2347:22 – CAM1 “three thousand RVR. We can’t land on that.”
CAM2 indicated RVR 2,400 ft, CAM1 “okay fine”
6. Accident Overview
2347:53 – second windshear alert, winds 350o at 32 kts gusts 45 kts
2348:12 – runway 4R RVR 1,600ft.
2348:24 – CAM2 stated they were on inbound ILS
Cleared to land winds 340o at 31 kts.
2349:24 – CAM2 “there’s the runway off to your right, got it?” CAM1 “no”
2349:57 – “aw.. we’re off course” (unidentified)
2350:00 – CAM2 “we’re way off”
2350:13-14 – GPWS “sink-rate”
2350:20 – Touchdown
2350:22 – CAM2 “we’re down, we’re sliding.”
7. Accident Overview
Landing
Crosswind limitations
Low RVR
Improper use of checklists and verification
Improperly configured for landing
Came to a stop 800’ beyond departure end of runway
11. Background
Captain
48
Hired in 1979
First class medical with no restrictions
Qualified captain July 31,1991.
Lt. Col. Air Force Reserves
TT: 10,234 hours, 5,518 hours MD-80
First Officer
35
Hired in January 1999
1st class no restrictions
Qualified FO on MD-80 February 22, 1999
TT: 4,292 hours
182 hours with AA
12. Human Factors
Stress Reduction
Scheduled Late at night
2 hour delay (unhappy pay; elected to get new aircraft)
Pilots fatigued, close to busting duty day
Severe get-there-it is
Crew did not discuss alternate
Group Climate
Inadequate assertion from FO
Unable to properly communicate concerns about weather
Binder
Inadequate Leadership from Captain
Bad workload management
No briefings, no bottom line discussion or personal minimums
13. Human Factors
Situational Awareness
No preparation, planning or vigilance (due to inadequate workload management and
communications)
Lead to loss of SA of the crew as Captain requested to switch runways and FO
accepted ILS approach.
Captain continued visual although he had accepted ILS approach
FO became overwhelmed
Weather updates
Visually identification of airport
Checklists
Final Items
14. Human Factors
Safety & Decision Making
Decision to Land in Adverse Weather
Should have established a bottom
Alternate (an early plan could’ve reduced the chance of busting duty day)
GO-AROUND anytime
Captain or FO decision
Never stabilized
Should’ve realized personal minimums
