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Safety Recommendation Details

Safety Recommendation A-01-058
Details
Synopsis: On June 1, 1999, at 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 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 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. 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.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: In cooperation with the National Weather Service, ensure that Center Weather Service Units are adequately staffed at all times when any significant weather is forecast.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate Action
Mode: Aviation
Location: LITTLE ROCK, AR, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA99MA060
Accident Reports: Runway Overrun During Landing, American Airlines Flight 1420, McDonnell Douglas MD-82
Report #: AAR-01-02
Accident Date: 6/1/1999
Issue Date: 12/10/2001
Date Closed: 4/6/2011
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Alternate Action)
Keyword(s): Weather, Staffing, Air Traffic Control

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/6/2011
Response: The FAA previously informed the NTSB that, together with the NWS, it had completed an assessment of the CWSU program that had identified a number of shortcomings and needed improvements, including the issues specified in these recommendations. The NWS and the FAA were planning to revise the CWSU program to address the issues identified by the assessment. The FAA’s current letter reveals that, although the revisions to CWSU are not yet complete, in July 2010 a short-term plan was implemented to ensure standardized, consistent, measurable, and continuous operations. We note that CWSUs operate 16 hours per day, 7 days per week, and that the NWS Weather Forecast Office provides support for the remaining 8 hours of each day. In addition, CWSUs now provide finer resolution forecast information for TRACONs. In view of the age of these recommendations (Safety Recommendation A-95-48 is 16 years old, and Safety Recommendation A-01-58 is 9 years old), the NTSB considered whether the actions taken to date meet our intent in issuing them. The FAA worked with the NWS to reevaluate the CWSU program, and procedures have been developed and implemented that enable meteorologists to disseminate information about rapidly developing hazardous weather conditions to TRACONs and tower facilities immediately upon detection. Therefore, although NWS and the FAA continue to make further improvements to the CWSU program, Safety Recommendation A-95-48 is classified “Closed—Acceptable Action.” Although CWSUs are not staffed 24 hours per day, 7 days per week as recommended, and may therefore be closed during periods of significant weather, the NTSB believes that the NWS Weather Forecast Office providing support for periods when the CWSU is not open constitutes an acceptable alternate response; consequently, Safety Recommendation A-01-58 is classified CLOSED – ACCEPTABLE ALTERNATE ACTION.

From: FAA
To: NTSB
Date: 2/7/2011
Response: CC# 201100065: - From J. Randolph Babbitt, Administrator: The Inter-Agency Agreement (IA) between the FAA and the NWS states that normal operating hours for the CWSU covers 16 hours/7 days per week. The remaining 8 hours will be covered by the local Weather Forecast Office. The IA states that actual hours and shift assignments are done by the Traffic Management officer within the ARTCC and the CWSU Meteorologist-In-Charge. This local provision exists to allow for flexibility in the schedule. CWSU personnel are to remain in the ARTCC when significant weather is expected. The correct level for this day-to-day scheduling takes place at the ARTCC level and is a standard operating procedure. A copy of the IA is enclosed. I believe that the FAA has effectively addressed safety recommendation A-OI-58, and I consider our actions complete. I will provide an update for A-95-48 in December 2011.

From: NTSB
To: FAA
Date: 9/13/2005
Response: The Safety Board notes that the FAA has completed an assessment of the current operations of the CWSU and has published the results of its assessment. This assessment identified a number of shortcomings and needed improvements to the CWSU program, including the issues described in these recommendations. The NWS and the FAA are now working collaboratively to bring about major changes, proposed by the NWS, in the current operations of the CWSUs. The FAA is reviewing a proposal for restructuring and consolidating the CWSUs and, together with the NWS, is preparing budget, planning, and implementation documents to bring about these changes. The FAA believes that the transformation of the CWSU system should be completed about 2 years after initiation of the restructuring effort. The Safety Board believes that the review of the CWSU program by the FAA and the NWS has identified many significant improvements, and the Board is pleased by the FAA's plan to implement these improvements. Pending implementation of the revised CWSU program, Safety Recommendations A-95-48 and A-01-58 remain classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 5/20/2005
Response: Letter Mail Controlled 6/1/2005 8:03:19 AM MC# 2050231 - From Marion C. Blakey, Administrator: The Federal Aviation Administration made a commitment to install Automated Surface Observing System-Information Display System (ACE-IDS) in towers and Terminal Radar Approach Control (TRACON) facilities for the rapid dissemination of information on hazardous weather. Therefore, the remaining element of this safety recommendation is to reevaluate the Center Weather Service Units (CWSU) program, and to standardize the CWSU operations on a national basis. The FAA completed its assessment of the current operations of the CWSU and has published the results of its assessment. I have enclosed a copy of the report for the Board's information. The assessment concluded that the mission of the CWSU was uncertain and was not reflected in current operations. The opportunity to provide modern weather services by the CWSUs was not being met. The intramural responsibility of the CWSUs for the distribution of weather information had not been fulfilled and to some extent had been overtaken by technology. Extramural collaboration did not usually occur. The training function had been misdirected or disabled. The level of services provided by the CWSU was uneven and sharply deficient. Thus, the value of the CWSU products and services were marginal and met only the lowest standard for meteorological support. The National Weather Service (NWS) has agreed to restructure the CWSUs based on the constraints and opportunities expressed in the FAA's "Guidelines for Restructuring of the CWSUs." I have enclosed a copy of the guidelines for the Board's information. The NWS has proposed major changes in the operation of the CWSUs in a report entitled "An Integrated Concept for Enhancing Weather Support to the NAS," which is also enclosed for the Board's information. The NWS and the FAA are now working collaboratively to bring about these changes in the current operations of the CWSUs. In particular, we have agreed on the following new mission: …to be cognizant of hazardous weather information covering all phases of flight, participate in strategic planning, and support the transition to tactical operations. The scope of this mission is defined by the needs of the national system of traffic management that meets objectives of safety, efficiency, and security. The FAA is reviewing a proposal for restructuring and consolidating the CWSUs. This restructuring would give continuous service over the entire continental United States and utilize the opportunities available in remote videolweb conferencing. Several new products have been proposed: (1) hourly Hub Forecasts at 35 major terminals; (2) TRACON forecasts and TRACON Advisories to improve the current Center Weather Advisory; and (3) an Interactive Weather Briefing. These new products and services would be available to all air route traffic control centers, TRACONs, and to most airport traffic control towers. Most of all, the restructuring proposal would directly address three critical issues that were identified in the assessment report--training, program management, and financial controls. These provisions will require an investment that would transform the current CWSUs into a more effective delivery point for aviation weather that conforms to national standards and maintains continuous surveillance of weather hazards. The FAA is evaluating an investment analysis of this proposal. Two documents are in draft--Mission and Concept of Operations and a Project Management Plan. Subsequently, the FAA expects the NWS to respond with an Implementation Plan that would complete the transformation of the CWSUs in about 2 years after initiation of the restructuring effort. During this period of uncertainty and planning, the Interagency Agreement has been extended until September 30, 2005. A new Interagency Agreement is under consideration, pending decisions by the FAA and NWS. Although it was anticipated that these efforts would be concluded in 2003, the significant accomplishments noted above have contributed substantially to the FAA reconsidering the design for delivering weather services. Changes in these concepts will be reflected in revised FAA orders, if needed. I will keep the Board informed of the FAA's progress on these efforts.

From: NTSB
To: FAA
Date: 2/23/2004
Response: The Safety Board notes that the FAA transferred the CWSU program to the Air Traffic Tactical Operations organization in January 2003. The FAA reports that since then, several actions have been initiated to resolve the issues identified in these safety recommendations. The FAA stated that these actions included a joint FAA/NWS review of the present program and development of guidelines for restructuring the program. The FAA stated that it also inventoried present CWSU facilities, initiated a functional audit of the current network of centers, and solicited input from center managers. The Safety Board appreciates the FAA's recent efforts to resolve the CWSU staffing and communication issues. The Board requests copies of (1) the guidelines written for restructuring the CWSU program and (2) the interim interagency agreement between the FAA and NWS for review. Pending completion of a revised mission and restructuring plan and development of a new FAA Order 7210.38, "Center Weather Service Unit," that addresses the intent of these two recommendations, Safety Recommendation A-95-48 is classified "Open--Acceptable Response" and A-01-58 remains classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 11/21/2003
Response: Letter Mail Controlled 12/2/2003 8:08:12 AM MC# 2030583 - From Marion C. Blakey, Administrator: The CWSU program were transferred to the Air Traffic Tactical Operations organization in January 2003. Several efforts to meet this recommendation were described: · FAA and NWS reviewed the present program · FAA and NWS wrote guidelines for restructuring the CWSU program. · A functional audit of the current center network was initiated. · NWS initiated a "vision team" for future configurations. · FAA conducted an inventory of CWSU facilities. · FAA solicited input from center mamangers. The FAA reported that for the transition period a new Interagency Agreement has been prepared. The restructuring plan for the CWSUs will be presented to the FAA and NWS in Dec 2003.

From: NTSB
To: FAA
Date: 5/6/2003
Response: The Safety Board notes the FAA's statement that responsibility for the CWSU program was recently transferred within the FAA from one office to another and that CWSU staffing alternatives are being evaluated to determine ways to improve safety and optimize services. We also note that a two-part study is being conducted to assess the operational meteorological services (staffing) and the products provided to FAA facilities by operational meteorologists and expert systems. The Safety Board looks forward to the results of the study and would appreciate reviewing a copy when it is completed. Pending the study's results, and implementation of the recommended action, Safety Recommendation A-01-58 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 2/21/2003
Response: Letter Mail Controlled 3/5/2003 4:40:23 PM MC# 2030124 - From Marion C. Blakey, Administrator: The primary function of the Center Weather Service Unit (CWSU) is to provide meteorological advice and consultation to air route traffic control center (ARTCC) operations personnel and other designated Federal Aviation Administration (FAA) air traffic facilities (terminal and automated flight service stations) within the ARTCC area of responsibility. The responsibility for the CWSU program was recently transferred from one office to another within the FAA, and CWSU staffing alternatives are being evaluated to determine ways to improve safety and optimize services. A two-part study is being conducted to assess the operational meteorological services (staffing) and the products provided to FAA facilities by operational meteorologists and expert systems. The objective is to evaluate operational weather services and products and to identify what changes need to be made to improve safety and optimize services. I will inform the Board of the outcome of the study once it is completed and the alternatives are evaluated.

From: NTSB
To: FAA
Date: 10/17/2002
Response: The Safety Board disagrees with the FAA that current procedures address the intent of the recommendation. In the Little Rock accident, even though the ARTCC facility manager was responsible for ensuring that a weather coordinator was assigned to each shift, the CWSU was closed for the evening when severe weather was predicted to affect the center's airspace. This recommendation is based on the concern that a CWSU may be closed when significant weather is forecast unless there is an explicit requirement that CWSUs be open and staffed whenever severe weather is predicted in a center's airspace. The Board further believes that relying solely on the ARTCC facility manager to ensure CWSU staffing during periods of significant weather without a specific requirement for the staffing is unlikely to be successful. The Board asks the FAA to reconsider its position on this recommendation. Pending the adoption of a requirement for CWSUs to be open and staffed whenever severe weather is predicted in a center's airspace, Safety Recommendation A-01-58 is classified OPEN -- UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 2/19/2002
Response: Letter Mail Controlled 02/21/2002 7:49:04 PM MC# 2020178 - From Jane F. Garvey, Administrator: The primary function of the Center Weather Service Unit (CWSU) is to provide meteorological advice and consultation to air route traffic control center (ARTCC) operations personnel and other designated FAA air traffic facilities (terminal and automated flight service stations) within the ARTCC area of responsibility. Currently, the ARTCC facility manager has operational responsibility for the CWSU and in accordance with Order 7210.38A, Center Weather Service Unit (CWSU), paragraph 11, must do the following: § make provisions to ensure a weather coordinator is assigned to each shift; and § develop a local order including the prioritization of duties. ARTCC facility managers will be reminded of their roles and responsibilities to the unit as detailed in Order 7210.38A. However, the current procedures address the full intent of this safety recommendation, and I consider the FAA's action to be completed.