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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: Develop specific criteria, using the Federal Railroad Administration's requirements as guidance, to be evaluated during a postaccident interagency emergency response critique, and amend 14 Code of Federal Regulations Part 139 to require airport operators to conduct this critique within 60 days after any air carrier accident and provide the results of the critique to the Federal Aviation Administration.
Original recommendation transmittal letter:
Closed - Acceptable Alternate 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 - Acceptable Alternate Action)
Airport Rescue and Firefighting, Emergency Response
Safety Recommendation History
On April 25, 2002, the FAA issued CERTALERT No. 02-03, “Air Carrier Accident Critique,” which identified the need for debriefs after drills, exercises, and actual emergencies. On November 22, 2002, the NTSB stated that, although we were pleased by the issuance of the CERTALERT, we were concerned that it did not require the results of the critiques to be reported to the FAA, as specified in the recommendation. We further explained that such a requirement was intended to enable the FAA to provide the results to other airports and emergency response teams that could benefit from the information. In its current letter, the FAA replied that it does not see the need to maintain the after-action critiques and feels this would be a duplication of the Federal Emergency Management Agency’s (FEMA) Lessons Learned Information Sharing website. FEMA also has issued a special report, titled “The After-Action Critique: Training Through Lessons Learned,” which the FAA believes provides sufficient guidance and addresses the FRA requirements for postaccident emergency response critiques. Accordingly, the FAA believes it is not necessary to amend Part 139 as recommended. We agree that FEMA’s activities constitute an acceptable alternative to the recommended action; consequently, Safety Recommendation A-01-67 is classified CLOSED—ACCEPTABLE ALTERNATE ACTION.
CC#201100305: - From J. Randolph Babbitt, Administrator: In our February 19, 2002, letter we reported that we intended to task the ARAC with reviewing the Federal Railroad Administration's (FRA) postaccident critique. Due to time constraints, the FAA chose not to task the ARAC with reviewing the FRA's postaccident critique. Therefore, the ARAC did not address the FRA's postaccident interagency emergency response critique. As mentioned in our May 14, 2002, letter to the Board, we issued CERTALERT, No. 02-03, Air Carrier Accident Critique. We have also revised AC l50/5200-31C, Airport Emergency Plan. The FAA has identified the need for debriefs after drills, exercises, and actual emergencies. The FAA stresses throughout the AC the need for critical incident stress debriefing as a part of the recovery and mental health process following critical events. The FAA does not see the need to maintain the after action critiques and feels this would be a duplication of effort since a secure Web site already exists for this exact purpose. The Federal Emergency Management Agency (FEMA) maintains the Lessons Learned Information Sharing (LUS) Web site at www.llis.dhs.gov.This provides an avenue for emergency responders and emergency management officials to share their lessons learned and experiences with a broad based community. Training on after action critiques is available in a special report developed specifically for FEMA. The special report is titled, The After-Action Critique: Training Through Lessons Learned, and is available at www.usfa.dhs.gov/downloads/pdf/publications/tr 159.pdf. The FAA believes this report provides sufficient guidance and is within the spirit of the FRA requirements for postaccident emergency response critiques. In addition, the FAA believes the LUS Web site provides the opportunity for emergency responders to benefit from experiences of others, which was a concern of the Board. Accordingly, the FAA believes it is not necessary to amend part 139 to require airports to conduct a postaccident interagency emergency response critique through a rulemaking process. I believe the FAA has effectively addressed this safety recommendation, and I consider our actions complete.
The FAA reports that it agrees with the intent of this safety recommendation and that on April 25, 2002, it issued a CERTALERT to all certificated airports encouraging them to hold a critique after an accident has taken place on their airports. The FAA further reports that the Aviation Rulemaking Advisory Committee's (ARAC) Airport Rescue and Fire Fighting (ARFF) Requirements Working Group is reviewing this recommendation in conjunction with its review of all Title 14 CFR Part 139 ARFF requirements. Although pleased by the FAA's issuance of the CERTALERT, the Safety Board notes that the CERTALERT does not discuss reporting the results of the critiques to the FAA, as specifically called for in the recommendation. The purpose of reporting the critique results to the FAA was so the FAA could make information from these critiques available to other airports and emergency response teams that may wish to benefit from the experience of others. We would appreciate knowing whether the ARFF Working Group will be considering this portion of the recommendation. Pending the results of the ARAC review, and implementation of the recommended action, including the requirement to report results of the critiques to the FAA, Safety Recommendation A-01-67 is classified OPEN -- ACCEPTABLE RESPONSE.
Letter Mail Controlled 06/10/2002 9:30:32 AM MC# 2020575 - From Jane F. Garvey, Administrator: The Federal Aviation Administration (FAA) agrees with the intent of this safety recommendation and on April 25, 2002, issued a CERTALERT to all certificated airports encouraging them to hold a critique after an accident has taken place on their airports. I have enclosed a copy of the CERTALERT for the Board's information. The Aviation Rulemaking Advisory Committee's (ARAC) ARFF Requirements Working Group is reviewing this recommendation in conjunction with its review of all 14 CFR Part 139 ARFF requirements. I will keep the Board informed of the FAA's progress on this effort.
Letter Mail Controlled 02/21/2002 7:49:04 PM MC# 2020178 - From Jane F. Garvey, Administrator: The FAA agrees with the intent of this safety recommendation and will ask the ARAC ARFF Requirements Working Group to review this recommendation in conjunction with its review of all of the 14 CFR Part 139 ARFF requirements. In the interim, the FAA will issue a CERTALERT to all certificated airports encouraging them to hold a critique after an accident has taken place on their airports.
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