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Safety Recommendation Details

Safety Recommendation A-01-069
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: Define detailed parameters for a stabilized approach, develop detailed criteria indicating when a missed approach should be performed, and ensure that all 14 Code of Federal Regulations Part 121 and 135 carriers include this information in their flight manuals and training programs.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable 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: 3/6/2012
Addressee(s) and Addressee Status: FAA (Closed - Unacceptable Action)
Keyword(s): Approach: Stabilized, Flightcrew, Go Around, Training and Education

Safety Recommendation History
From: NTSB
To: FAA
Date: 4/30/2012
Response: Notation 8406: The National Transportation Safety Board (NTSB) has reviewed the Federal Aviation Administration’s (FAA) notice of proposed rulemaking (NPRM) titled “Pilot Certification and Qualification Requirements for Air Carrier Operations,” which was published at 77 Federal Register (FR) 12374 on February 29, 2012. The notice proposes to create new certification requirements for pilots in air carrier operations, including requiring that first officers in 14 Code of Federal Regulations (CFR) Part 121 operations hold an airline transport pilot (ATP) certificate and type rating for the aircraft to be flown; allowing pilots with an aviation degree or military pilot experience but fewer than 1,500 hours total time as a pilot to obtain an ATP certificate with restricted privileges; and requiring at least 1,000 flight hours in air carrier operations to serve as pilot in–command (PIC) in Part 121 air carrier operations. The notice also proposes to modify the requirements for obtaining an ATP certificate with an airplane category multiengine class rating or type rating to require 50 hours of multiengine flight experience and completion of a new FAA-approved ATP certificate training program that would include academic training and training in a flight simulation training device. According to the NPRM, these changes would help to ensure that pilots entering an air carrier environment have the training and aeronautical experience necessary to adapt to a complex, multicrew environment in a variety of operating conditions. The NPRM cites the 2009 Colgan Air accident near Buffalo, New York, as an event that focused public, congressional, and industry attention on flight crew experience requirements and training for conducting Part 121 air carrier operations. In February 2010, the FAA published an advance notice of proposed rulemaking (ANPRM), titled “New Pilot Certification Requirements for Air Carrier Operations” (75 FR 6164, February 8, 2010) that sought input on current Part 121 eligibility, training, and qualification requirements for seconds-in-command (SICs). The current NPRM is based on comments in response to the ANPRM, input received from an aviation rulemaking committee established in July 2010, and statutory requirements for modifying ATP certification outlined in the Airline Safety and Federal Aviation Administration Extension Act of 2010 (Public Law 111-216). Adding to that foundation, the NPRM states that the FAA conducted a study of 61 NTSB investigation reports from fiscal year (FY) 2001 through FY 2010 (31 Part 121 accidents and 30 Part 135 air carrier accidents, with 107 fatalities, 28 serious injuries, and 44 minor injuries). The study showed that the accidents examined involved pilot deficiencies in aircraft handling, including stall and upset recognition and recovery, high altitude training, active pilot monitoring skills, effective crew resource management (CRM), stabilized approaches, operations in icing conditions, and hypoxia training. The NPRM asserts that the changes to air carrier pilot qualification would address, in part, 21 NTSB safety recommendations in the following areas: Safety Issue Recommendations Training flight crews to respond to sudden, unusual, or unexpected aircraft upsets: A-96-120, A-04-62, A-07-3, and A-09-113 Developing and conducting stall recovery training and providing stickpusher familiarization training for pilots of stickpusher-equipped aircraft: A-10-22 and -23 Training in high altitude operations: A-07-1 and -2 Training and guidance for rudder use in transport-category aircraft: A-02-2 Airport situational awareness: A-07-44 Stabilized approach concept: A 01 69 and A-08-18 Landing performance calculations: A-07-59 and A-08-41 CRM training: A-03-52 Pilot monitoring duties: A-10-10 Requirements for flight crewmember academic training regarding leadership and professionalism: A-10-15 Training in icing conditions: A-07-14 Hypoxia awareness training: A 00 110 Training in landing and taking off in crosswinds with gusts: A 10-110 and -111 The NTSB is generally supportive of the proposed rule as it relates to many of the issues previously identified in our safety recommendations. Specific comments on several areas of the NPRM follow. Academic Credit To Reduce Flight Experience Requirements Although the NTSB has not made recommendations for flight hour minimums for air carrier pilots (instead focusing its recommendations on specific procedures and training, needed regulations, and needed guidance to crews and operators), we stated in our comments on the ANPRM that: Ensuring a high level of knowledge, skills, and professionalism for flight crewmembers is essential, but total flight hours or an airline transport pilot certificate does not necessarily equate to the level of knowledge, skills, and professionalism required for consistently safe flight operations. The comments went on to state that, “the NTSB recognizes the value of academic training for air carrier pilots, but the NTSB also believes that academic training is not a substitute for practical experience.” An important tenet in the recent NPRM is the concept that, “in certain circumstances, the combination of focused academic training and structured flight training can substitute for actual flight experience” (p. 12379). The NTSB concurs with the FAA’s acknowledgement that there may be multiple pathways to becoming a qualified air carrier pilot. However, there remain unresolved issues for how academic credit should be applied, including student performance within an accredited academic program and the type of degree conferred. These issues are not addressed in the NPRM and require more evaluation before this proposal is implemented. It is essential that the content and rigor involved in academic training be clearly defined and, most importantly, appropriate resources allocated to conduct evaluation and oversight of these alternative methods of qualification. ATP Certification Training Program The NPRM discusses the establishment of an FAA-approved ATP certificate training program for a multiengine class ATP or type rating. The proposed training program outlined under section 61.154 would include 24 hours of classroom training and 16 hours of simulator training (8 in a full flight simulator of at least Level C standards) and is intended to provide pilots with the core knowledge and understanding in areas critical to operating high performance aircraft in a complex and high altitude environment. The training would be provided by an authorized training provider and would be required to be completed before a pilot would be eligible to take the ATP knowledge test. Issued as part of the NPRM, draft Advisory Circular (AC) 61-ATP, “Airline Transport Pilot Certification Training Program for Airplane Category Multiengine Class Rating or Type Rating,” contains an outline of the curriculum topics and objectives for both the classroom and simulator training making up this training program. The AC is intended for use by training providers when developing the program and by the FAA when reviewing and approving the programs. Many of the topics contained in the draft AC address issues from NTSB safety recommendations; in fact, the FAA notes that most of the 21 recommendations cited in the NPRM are addressed, in part, by the proposed amendments and advisory material. Although the NTSB concurs with the FAA’s assessment that, in most cases, the topics addressed will serve to partially satisfy the action requested in existing recommendations, the amount of specificity provided in the proposed rule and AC does not allow a comprehensive review of the degree to which the FAA’s proposed actions would satisfy the intent of the NTSB’s recommendations. In some instances, neither document provides evidence that a recommendation topic is addressed. The NTSB notes that recent safety recommendations in this area have focused on attempts to improve crew response to in-flight emergencies, including task prioritization and training. While AC 61-ATP does include a classroom training objective named “differences between emergency and non-normal checklist procedures and checklists,” the guidance on emergency procedures should be made more explicit to incorporate the issues identified in these NTSB recommendations. CRM is another topic relevant to previous NTSB recommendations and outlined in AC 61-ATP. However, the list of proposed topics in the AC does not explicitly refer to the importance of first officer assertiveness, which is an issue addressed in Safety Recommendation A-11-39. This recommendation is not cited in the NPRM, but the NTSB believes that it is within the scope of the draft advisory material and suggests amending the AC to include information consistent with Safety Recommendation A-11-39 to help support this important aspect of CRM. The NTSB is encouraged that the NPRM proposes to centralize the process for approving ATP certification training programs. Specifically, the NPRM states that only authorized training providers can administer the training required under section 61.154. These providers can be certificate holders providing training and operating under Parts 141, 142, 121, or 135, and each provider must receive approval of their ATP certification training program by the FAA Air Transportation Division (AFS-200). The NTSB notes that, theoretically, centralization should help to ensure standardization of these programs, but suggests that additional guidance documentation with more specific and robust detail about the content of the proposed training is necessary to provide a solid foundation on which the FAA can evaluate the program content (and to assist training providers to develop courses likely to receive FAA approval). For example, additional detail, such as cross-referencing material from draft AC 120-STALL, would be appropriate in the discussion of stall training in AC 61-ATP. In addition, the FAA will need to provide the appropriate oversight resources to these programs—not only in their initial approval but also to conduct ongoing oversight to demonstrate that the content delivered is consistent with the approved program. The rigor with which these programs are implemented and overseen will determine their ultimate influence on improving safety in air carrier operations. Pilot-in-Command Requirements for Air Carrier Operations The NPRM proposes primarily experience-based requirements for new PICs in air carrier operations. However, the NTSB has previously issued safety recommendations addressing the need for a specific leadership training course for upgrading captains. Although the NPRM cites Safety Recommendation A-10-15 and describes it as applicable to leadership and professionalism training, it addresses only the latter topic. The NPRM does not mention Safety Recommendations A-10-13 and -14, which were issued with -15, but the NTSB believes that a leadership training course for upgrading captains is within the scope of the proposed rulemaking and that section 121.436 should be amended to include a specific requirement for such a course. In addition to the requirements already outlined in section 121.434, the NTSB has recommended that Part 135 pilots who need a type rating for the aircraft they fly be required to have a minimum level of initial operating experience. Given the applicability of the NPRM to Part 135 pilots who are engaged in air carrier operations, the NTSB believes it would be appropriate to incorporate similar experience requirements for these pilots as exist for Part 121 pilots. The NTSB supports the use of simulators in training environments and notes that the training program outlined in the NPRM specifies that training on topics such as low energy states/stalls and upset recovery techniques will be conducted in a Level C or higher full-flight simulator. Simulators, regardless of their fidelity, are dependent on their physical limits of motion, as well as the efficacy of the available computer programs (which are often limited in issues of upset training because of the lack of flight test data at the extreme areas of the flight envelope). Simulators are not always adequate in portraying upsets and stalls and may inadvertently introduce negative training. Consistent with Safety Recommendation A-04-62, the FAA should allow flexibility in determining what level of simulation or automation is appropriate for specific training. Summary Observations This NPRM addresses many training issues applicable to becoming an air carrier pilot, including some critical issues demonstrated in recent accident history to be responsible for accidents. The NTSB is encouraged that its recommendations were considered in the development of this proposed rule, especially as the issue areas relate to the core content to be provided to new entrant pilots through the ATP certification training program. However, the intent of our recommendations in this area is for all pilots to receive training in these topics. Therefore, it is important that air carriers provide equally robust training in these topic areas for their current air carrier pilots on a recurrent basis. The NTSB appreciates the opportunity to comment on this NPRM.

From: NTSB
To: FAA
Date: 3/6/2012
Response: During our investigation of the American Airlines flight 1420 accident in Little Rock, we asked American Airline’s MD-80 Chief Pilot whether an airplane that was off by 1 dot, 2 dots, or even a full scale deflection of the glideslope indicator and/or localizer would be considered a stabilized approach. He replied that it would be the captain’s decision. When informed of this ambiguity, American Airlines developed the specific stabilized approach criteria we recommended. Safety Recommendation A-01-69 was issued to the FAA because no FAA guidance existed to define an unacceptable deviation on the localizer and/or glideslope, and because the procedures in effect at American Airlines at the time of the Little Rock accident were allowed under existing FAA regulations. Since this recommendation was issued, the FAA has maintained (1) that it strongly supports the use of stabilized approach procedures and (2) that FAA inspectors review a carrier’s stabilized approach procedures. This guidance is contained in advisory circular (AC) 120-71A, “Standard Operating Procedures for Flight Deck Crewmembers” and in FAA Order 8900.1 In particular, Appendix 2 of the AC contains the FAA’s guidance on stabilized approaches, and the criteria that should be used. It focuses on establishing approach gates, which are reference points for flight crews to monitor the quality of their progress during an approach to a landing and to promote their situational awareness, and on establishing points at which vertical and lateral deviation limits should be noted and stabilized approach criteria should be checked. We believe that the use of approach gates during a stabilized approach is helpful, but this technique does not include the specific criteria recommended (such as no more than a 1-dot deviation on the glideslope indicator and/or localizer). Our review of AC 120-71A and relevant guidance in FAA Order 8900.1 did not identify the specific guidance on glideslope indicator and/or localizer deviations that we recommended in Safety Recommendation A-01-69. Nevertheless, the FAA has indicated that it considers its actions in response to this recommendation to be complete; consequently, Safety Recommendation A-01-69 is classified CLOSED—UNACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 1/4/2012
Response: -From Michael P. Huerta, Acting Administrator: The stabilized approach is acknowledged as one of the key features of safe approaches and landings in air carrier operations, especially those involving transport category airplanes. As stated in the Federal Aviation Administration's (FAA) February 19, 2002, letter to the Board, this subject was exhaustively studied by a highly qualified working group under the Commercial Aviation Safety Team, resulting in many related products, including Advisory Circular (AC) 120-71, Standard Operating Procedures for Flight Deck Crewmembers. In its October 17, 2002, letter, the Board expressed concern that FAA guidance on stabilized approaches did not provide sufficient detail. On February 27, 2003, the FAA issued AC 120-7IA, Standard Operating Procedures for Flight Deck Crewmembers (available here: http://rgLfaa.gov/Regulatory_and_Guidance_Library/rgAdvisoryCircular.nsf/list/AC%20120-71N$FILE/AC120-71A.pdf). This AC describes the stabilized approach as one of the most important elements of flight, and includes detailed criteria with explicit guidance that the stabilized approach should be established no later than 1,000 feet above ground level in instrument meteorological conditions and no later than 500 feet above ground level in visual meteorological conditions. The stabilized approach should be maintained until the landing maneuver begins. Included in AC 120-7IA, Appendix I, is the recommended practice of establishing approach gates. Approach gates are established by the operator as reference points for flight crews to monitor the quality of their progress during an approach to a landing and to promote their situational awareness. Approach gates are points at which vertical and lateral deviation limits are noted and stabilized approach criteria are checked. These criteria indicate whether an approach can continue or a missed approach should be executed. Approach gates can be used in addition to already existing criteria for missed approaches. Principal Operations Inspector (POI) guidance for all categories of approaches, regarding the requirement that stabilized approach procedures must be part of an operator's program, is found in FAA Order 8900.1, Flight Standards Information Management System, Volume 4, Chapter 2, Section 3, Paragraph 4-221, Stabilized Approach Concept: ... Operators of turbojet aircraft must establish and use procedures that result in stabilized approaches. Pilots operating propeller driven aircraft should also maintain a stable speed and flightpath on final approach. A stabilized approach must be established before descending below the following minimum stabilized approach heights: • 500 feet above the airport elevation during visual flight rules (VFR) or visual approaches and during straight-in instrument approaches in VFR weather conditions; • Minimum decent altitude or 500 feet above airport elevation, whichever is lower, if a circling maneuver is to be conducted after completing an instrument approach; • 1,000 feet above the airport or touchdown zone elevation during any straight-in instrument approach in IFR conditions; and • 1,000 feet above the airport during contact approaches. NOTE: POIs shall not approve an operator's procedures unless the stabilized approach concept is used for all turbojet aircraft operations. It is recommended for all propeller driven aircraft and rotorcraft in IFR weather conditions. Order 8900.1 also describes specific items POls review during enroute surveillance, which include a stabilized approach in the landing configuration. The approach should reflect the operator's procedures, and must include stabilized approach guidance for all categories of approaches for which an operator is approved in their training programs as well as their manuals that describe approach procedures. These procedures must contain a description of acceptable deviations from both external or aircraft generated electronic glideslopes and lateral tracks when covering instrument approach procedures. Air carriers are additionally encouraged to adopt, at a minimum, the tolerances prescribed in the instrument and/or airline transport pilot practical test standards. Once the operator's training programs are approved, the operator is not free to revise these procedures without their POI's approval. I believe that the FAA provides clear stabilized approach guidance that effectively addresses this recommendation, and I consider our actions complete.

From: NTSB
To: FAA
Date: 10/17/2002
Response: The Safety Board disagrees that the FAA's actions meet the intent of the recommendation. In AC 120-71, including the appendices, the FAA has not defined stabilized approach parameters in sufficient detail. For example, the AC defines an approach as stabilized when the airplane is on the correct track, and on the glideslope. However, the AC does not define what are acceptable deviations from the glideslope and track for a stabilized approach. The Board notes that the AC states that the guidance for the correct track only pertains to Category II and Category III approaches. Most instrument landing system (ILS) approaches are Category I, and the FAA has indicated that guidance for Category I approaches is under development. In the accident that prompted this recommendation, the crew was performing a Category I ILS approach. More comprehensive and detailed guidance to indicate when a pilot is on a correct flightpath is needed to meet the intent of the recommendation. The FAA guidance says that it is acceptable to continue with an approach if a pilot is off the correct flightpath but needs only "normal bracketing" to correct back to course. In the AC, the FAA defines "normal bracketing" as being based on several criteria including "overshoots." The Board believes that the definition of "overshoots" is not sufficiently detailed to provide the needed guidance to pilots and operators. During the investigation of the American 1420 accident, the Safety Board polled several different major air carriers on their criteria for a stabilized approach. This poll of the major carriers found different opinions as to what would be acceptable deviations from the correct track and glideslope, and at what point in time these deviations would become unacceptable. The Board believes specific indicators on cockpit instrumentation can give more precise guidance to a crew as to what is an acceptable deviation. The intent of this recommendation is to develop and issue this type of detailed and improved deviation guidance. Pending review of detailed guidance for a stabilized approach, including for Category I approaches, Safety Recommendation A-01-69 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 stabilized approach is acknowledged as one of the key features of safe approaches and landings in air carrier operations, especially those involving transport-category airplanes. The subject was exhaustively studied by a highly qualified working group under the CAST, resulting in many related products, including an FAA AC. On August 10, 2000, the FAA issued Appendix 2 to AC 120-71, Standard Operating Procedures for Flightdeck Crewmembers. The AC includes the stabilized approach as one of the most important elements and includes detailed criteria with explicit guidance that the stabilized approach should be established no later than 1000 feet above ground level in instrument meteorological conditions and no later than 500 feet above ground level in visual meteorological conditions. The stabilized approach should be maintained until the landing maneuver begins, using normal bracketing corrections. Also included in Appendix 1 to AC 120-71 is the recommended practice of establishing approach gates. Approach gates are points established by the operator as reference points for flightcrews to monitor the quality of their progress during an approach to a landing and to promote their situation awareness. Approach gates are points at which vertical and lateral deviation limits are noted and stabilized approach criteria are checked. These criteria indicate whether an approach can continue or a missed approach should be executed. On October 31, 2001, the FAA issued Flight Standards Bulletin for Air Transportation 01-12, Approach and Landing Accident Reduction (ALAR): Recommended Flightcrew Training. The bulletin points to AC 120-71, the Flight Safety Foundation's Approach and Landing Accident Reduction (ALAR) Toolkit, and the ALAR Training Guide developed by a joint FAA-industry working group. I have enclosed a copy of the bulletin and the ALAR Training Guide for the Board's information. The guide reiterates the importance of approach gates. In February the FAA will launch a survey of ALAR training currently being conducted by 14 CFR Part 121 air carriers. Two of the questions on the survey are: § Does the air carrier's approved training program provide flight training in stabilized approaches? § Does the air carrier's approved training program provide flight training in go-around gates and missed approach criteria? I believe that the FAA has addressed the full intent of this safety recommendation.