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General Aviation Safety
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.
TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate crash detection and location technologies, select the most promising candidate(s) for ensuring that emergency responders could expeditiously arrive at an accident scene, and implement a requirement to install and use the equipment.
Original recommendation transmittal letter:
Closed - Unacceptable Action
LITTLE ROCK, AR, United States
Runway Overrun During Landing, American Airlines Flight 1420, McDonnell Douglas MD-82
Addressee(s) and Addressee Status:
FAA (Closed - Unacceptable Action)
Airport Rescue and Firefighting, Emergency Locator Transmitter
Safety Recommendation History
On June 12, 2009, the FAA issued Advisory Circular (AC) 150/5210-19A, “Driver's Enhanced Vision System (DEVS),” which provides guidance for the design and installation of DEVS equipment on ARFF vehicles. The FAA evaluated DEVS at its William J. Hughes Technical Center in Atlantic City, New Jersey, and at several airports around the country. AC 150/5220-10E, “Guide Specification for Aircraft Rescue and Fire Fighting (ARFF) Vehicles,” specifies the requirements for ARFF vehicles purchased by airports with FAA financial support, which constitute most of the ARFF vehicles in service. AC 150/5220-10E requires all new ARFF vehicles, regardless of size, to be equipped with a forward-looking infrared (FLIR) system. The NTSB notes that a FLIR system is a component of DEVS but that DEVS includes more than FLIR. The FAA also stated that its January 1, 2020, scheduled deployment of Automatic Dependent Surveillance-Broadcast (ADS-B) technology on all aircraft may provide the ability for an ARFF vehicle to receive accurate and timely location information for an airplane that has crashed. The NTSB disagrees with the FAA that new air traffic control technologies, such as ADS B combined with FLIR systems mounted on ARFF vehicles, would constitute an effective response to this recommendation. Safety Recommendation A-01-66 was reiterated in our report on the April 12, 2007, accident involving Pinnacle Airlines flight 4712, which overran the runway while landing in Traverse City, Michigan. In that accident, the ARFF responder reported that, although he had heard that the accident site was somewhere along runway 10/28, he initially had difficulty determining the airplane’s location along the length of that runway, despite his use of FLIR equipment, in part because of snow-restricted visibilitiy. In our report on that accident investigation, we concluded that The forward-looking infrared equipment installed in the aircraft rescue and firefighting (ARFF) vehicle did not help the firefighter locate the accident airplane; however, improved crash detection and location equipment would likely have facilitated a more timely ARFF response. The implementation of DEVS would satisfy this recommendation, but AC 150/5220-10E does not require a full DEVS. The NTSB’s experience investigating relevant accidents has shown that, although FLIR may be beneficial, its installation in ARFF vehicles does not satisfy this recommendation. ADS-B technology may present a basis for an effective response to this recommendation, but ADS-B will not be required until almost 20 years after this recommendation was issued, and the FAA has provided no definitive plans of how it would use ADS-B technology in this application nor has it committed to issuing a requirement for the installation of the needed equipment on ARFF vehicles. Because the FAA has stated that it considers it actions in response to this recommendation to be complete and plans no further action, Safety Recommendation A-01-66 is classified CLOSED—UNACCEPTABLE ACTION.
CC#201100305: - From J. Randolph Babbitt, Administrator: The FAA evaluated crash detection and location technologies. As a result, the FAA issued Advisory Circular (AC) 150/5210-19A, Driver's Enhanced Vision System (DEVS), on June 12, 2009. This AC provides guidance for the design and installation of Driver's Enhanced Vision System (DEVS) equipment on ARFF vehicles and is available at www.faa.gov/regulations_policies/rulemaking/committees/arac/media/apc/ACP_RFR_TI.pdf DEVS is comprised of vision enhancement, navigation, and tracking components. The greatest benefits may be realized at airports with operations when runway visual range is less than or equal to 1,200 feet. DEVS is used in an effort to reduce response times and is aimed at the four difficult aspects of poor visibility response: 1. Locating the accident; 2. Navigating to the accident site; 3. Avoiding obstacles; and 4. Locating people on the way to the accident site. Evaluations conducted at the FAA William J. Hughes Technical Center and airports around the country have demonstrated that DEVS technology can improve a driver's ability in these areas. AC I50/5220-1 OE, Guide Specification for Aircraft Rescue and Fire Fighting (ARFF) Vehicles, requires all new ARFF vehicles, regardless of size, to be equipped with a forward looking infrared system (FURS). This is an improvement over the previous requirement for ARFF vehicles to be equipped with FURS only when exceeding 1,000 gallons in size. This equipment allows the driver of an ARFF vehicle to be able to locate, within certain limits, a specific object, like an aircraft, during periods of low visibility. The FAA believes this is a significant increase in safety and in the capabilities of ARFF vehicles. The FAA is in the process of deploying several systems and technologies to help reduce the number and severity of incidents and accidents involving aircraft and vehicles at airports that have potentially serious consequences. The Automatic Dependent Surveillance-Broadcast (ADS-B) has been identified as a cornerstone technology in the FAA's Next Generation Air Transportation System initiative to modernize the safety, efficiency, and capacity of the National Airspace System. ADS-B will provide improved surveillance in the terminal, en route, and surface environments by providing pilots, air traffic controllers, and vehicle operators (including ARFF personnel) global positioning system position reports from the aircraft once every second. Initially, only airports using airport surface detection equipment will be able to utilize this technology. The FAA published a final rule, Automatic Dependent Surveillance-Broadcast (ADS-B) Out Performance Requirements to Support Air Traffic Control (ATC) Service, on May 28, 2010. This rule requires ADS-B Out equipage by January 1, 2020, for aircraft operating in certain airspace. The new air traffic control technologies combined with FURS mounted on ARFF vehicles enables emergency responders to respond in an expeditious manner to aircraft accidents/incidents. I believe the FAA has effectively addressed this safety recommendation, and I consider our actions complete.
Safety Recommendation A-01-66 was reiterated by the safety recommendation letter issuing A-08-40 thru 43 on 6/17/2008. This greensheet discusses an April 12, 2007 accident of a Bombardier/Canadair Regional Jet (CRJ) CL600-2B19, N8905F, operated as Pinnacle Airlines flight 4712, which ran off the departure end of runway 28 after landing at Cherry Capital Airport (TVC), Traverse City, Michigan.
The Safety Board notes that the intent of this recommendation is much broader than accidents and incidents where visibility from the tower is restricted due to weather. The recommendation asks that the FAA evaluate technology, such as an emergency locator transmitter, for crash detection and location (emphasis added) that would aid ARFF crews in detecting and locating a crashed airplane in situations regardless of the weather or visibility. Although the installation of FLIR technology is a positive step, its deployment does not satisfy the full intent of this recommendation. The Board notes that the requirement for FLIR predates the recommendation and the Little Rock accident and that, despite the existence of the FLIR requirement, none of the ARFF equipment that responded in Little Rock was equipped with a FLIR system. FLIR may assist with crash location, but it does not address crash detection. The Safety Board is aware of accidents in which an airplane crashes while landing. There is a period of time between when the crash occurs and when the controller initiates the ARFF system and the ARFF crews are able to locate the accident. During this time, the controller may be verifying whether there is a crash and still be trying to locate and communicate with the aircraft in question. If a crash detection and location system were in place, the emergency response would start as soon as an airplane crashed, avoiding the delay. In the Board's report on the Little Rock, Arkansas, accident, the Board noted the following three accidents in which the emergency response was delayed because the crash was not detected or the wreckage was not located in a timely manner: 1. Runway collision between Northwest Airlines Flights 1482 and 299, Detroit, Michigan, Boeing 727 and McDonnell-Douglas DC-9, December 3, 1990. 2. Flight into terrain during a missed approach, USAir Flight 1016, Charlotte, North Carolina, McDonnell-Douglas DC-9, July 2, 1994. 3. Ground Impact of American Airlines 1340, Boeing 727, Chicago, Illinois, February 9, 1998. In addition, the Board notes two other recent fatal accidents in which the emergency response was delayed because the crash was not detected or the wreckage was not located in a timely manner: 1. Controlled Flight into Terrain Korean Air Flight 801, Boeing 747-300, HL7468 Nimitz Hill, Guam August, 6, 1997. 2. Crash short of runway, Gates Learjet 25B, N627WS, Houston, Texas, January 13, 1998. It should be noted that in the Learjet accident, because they could not locate the wreckage, the ARFF crews did not arrive at the scene of the accident until 2 hours after it had occurred. The accident scene was 2 miles short of the runway where the Learjet was attempting to land. The Safety Board believes that FLIR would have been of little value in speeding the emergency response to any of these accidents except for the Detroit runway collision. The Safety Board asks the FAA to evaluate crash detection and location technology as recommended. Pending such an evaluation and implementation of a requirement for such equipment, Safety Recommendation A-01-66 is classified OPEN -- UNACCEPTABLE RESPONSE.
Letter Mail Controlled 02/21/2002 7:49:04 PM MC# 2020178 - From Jane F. Garvey, Administrator: The FAA agrees that emergency responders must be able to proceed expeditiously to the location of an airport accident. Due to limited visibility on the ground, the firefighters traditionally depend on personnel in the airport traffic control tower to locate the scene of an accident or incident and relay the site location to them. However, there are incidents when the visibility from the tower is restricted due to weather. As a result, the FAA revised paragraph 59a of AC 150/5220-l0B, Guide Specification for Water/Foam Aircraft Rescue and Firefighting Vehicles, to require that all new vehicles carrying 1,000 gallons or more of water and purchased with Federal funds be equipped with a forward looking infrared camera and monitor. This equipment allows an ARFF driver to drive in periods of low visibility and to be able to locate, within certain limits, a specific object like an aircraft. In response to Safety Recommendation A-01-62, the FAA is issuing a mandatory briefing item to tower controllers to emphasize that location information provided to ARFF crew should be as complete and specific as possible to minimize opportunities for confusion. The FAA believes that between the forward-looking infrared system capabilities and the emergency response coordination with tower controllers, emergency responders are able to respond quickly to virtually every recent on-airport accident or incident. I believe that the FAA has addressed the full intent of this safety recommendation, and I consider the FAA's action to be completed.
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