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Safety Recommendation Details

Safety Recommendation A-01-064
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: Amend Federal Aviation Administration (FAA) Order 7210.3R, "Facility Operation and Administration," to direct tower managers to establish mutual annual briefings between air traffic control (ATC) and Aircraft Rescue and Fire Fighting (ARFF) personnel to ensure that these personnel have a common understanding of the local airport emergency plan and sections of the FAA's Advisory Circular 150/5210-7C, "Aircraft Rescue and Firefighting Communications," that are applicable to local ATC/ARFF emergency response procedures.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable 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: 1/30/2004
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s): Air Traffic Control, Airport Rescue and Firefighting, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 1/30/2004
Response: FAA Order 7210.3, Paragraph 2-l-9, "Airport Emergency Plans," requires tower facility managers to issue operational instructions in the form of a letter of agreement. The Safety Board notes that in the publication of the order, the FAA plans to add a note in paragraph 2-l-9 advising facility managers to meet with ARFF personnel on an annual basis to review the letter of agreement. In the interim, the FAA has published a notice, effective November 1, 2003, to implement the change until the order is revised. The Safety Board believes that the FAA's actions (adding the note to paragraph 2-1-9 and publishing the November 1, 2003, notice) are responsive to the intent of this recommendation. Therefore, Safety Recommendation A-01-64 is classified "Closed--Acceptable Action."

From: FAA
To: NTSB
Date: 8/29/2003
Response: Letter Mail Controlled 9/2/2003 2:51:02 PM MC# 2030441 The procedures contained in Federal Aviation Administration (FAA) Order 7210.3, Facility Operation and Administration, paragraph 2-l-9, Airport Emergency Plans, clearly state the requirements of the facility manager to issue operational instructions in the form of a letter of agreement. This order also cites the responsibility of tower personnel to alert aircraft rescue and firefighting (ARFF) of the situation and provides clear and explicit requirements for issuing the alert, including a route to be taken to the scene, and the category of the alert. The FAA added a note in Order 7210.3, paragraph 2-l-9, to advise facility managers to meet with ARFF personnel on an annual basis to review the letter of agreement concerning local airport emergency services and the effectiveness of local procedures. The change will appear in the August 2004 publication of the order. In the interim, the FAA published a notice, effective November 1, 2003, to implement the change until the order is revised. I have enclosed a copy of the notice for the Board's information. I believe that the FAA has satisfactorily responded to this safety recommendation, and I look forward to your response.

From: NTSB
To: FAA
Date: 10/17/2002
Response: The FAA does not believe there is a need to implement an annual review between controllers and ARFF personnel. The FAA indicates that Order 7210.3R states that a tower facility manager is required to issue operational instructions in the form of a letter of agreement for coordinating ATC and ARFF activities. This order also cites the responsibility of tower personnel to alert ARFF of an emergency situation and provides clear and explicit requirements for issuing the alert, including a route to be taken to the scene and the category of the alert. The Safety Board disagrees with the FAA and continues to believe that a mutual annual briefing between ATC and ARFF personnel would be beneficial. The FAA's actions in response to Safety Recommendations A-01-62 and -63 should address the serious misunderstandings between ATC and ARFF personnel in the Little Rock accident which delayed the emergency response to the accident and occurred despite the orders and procedures that the FAA references. The Board believes that an annual briefing between ARFF and ATC personnel is a sound management practice that may lead to the discovery of misunderstandings, differences in terminology, or the need to change existing agreements before these problems are discovered during an emergency. Thus, the burden of an annual meeting is outweighed by the potential safety benefits. The Board asks the FAA to reconsider its position on this recommendation. Pending the FAA's reconsideration, Safety Recommendation A-01-64 is classified "Open--Unacceptable Response."

From: FAA
To: NTSB
Date: 2/19/2002
Response: Letter Mail Controlled 9/2/2003 2:51:02 PM MC# 2030441 The procedures contained in Federal Aviation Administration (FAA) Order 7210.3, Facility Operation and Administration, paragraph 2-l-9, Airport Emergency Plans, clearly state the requirements of the facility manager to issue operational instructions in the form of a letter of agreement. This order also cites the responsibility of tower personnel to alert aircraft rescue and firefighting (ARFF) of the situation and provides clear and explicit requirements for issuing the alert, including a route to be taken to the scene, and the category of the alert. The FAA added a note in Order 7210.3, paragraph 2-l-9, to advise facility managers to meet with ARFF personnel on an annual basis to review the letter of agreement concerning local airport emergency services and the effectiveness of local procedures. The change will appear in the August 2004 publication of the order. In the interim, the FAA published a notice, effective November 1, 2003, to implement the change until the order is revised. I have enclosed a copy of the notice for the Board's information. I believe that the FAA has satisfactorily responded to this safety recommendation, and I look forward to your response.