The crew on this MD-82 was highly qualified and accomplished. The captain was an Air Force veteran and a highly experienced check airman with American Airlines. His record was enviable. The first officer was new to American Airlines but was a Navy veteran with a good record. And yet they made a series of foolish mistakes that I am sure neither would have made the day before or the day after. What happened?
The NTSB report cited the crew's failure to abandon the approach and failure to arm the automatic ground spoilers. The crosswinds were above their company's stated maximum for a wet runway. At one point the captain said, "I hate droning around visual at night in weather without, having some clue where I am." No doubt about it, the approach should have been abandoned. Why did they start the approach, why did they continue the approach, and why didn't they go around and divert?
Experienced pilots know the reason: get-there-itis. We all have a mission-oriented instinct to get to our destination. It is, after all, our job.
This airline crew had that schedule pressure and I am told it was ingrained in many American Airlines pilots at the time. I am also told that culture has changed.
As corporate pilots, we are subjected to get-there-itis on steroids. We often know our passengers by name and know that getting them to their destination is good for them, good for the company, and good for us. If an airline pilot diverts, his next load of passengers are unlikely to be the same or to have any idea about what happened on the previous flight. We will see our passengers again.
As this mishap illustrates, get-there-itis worsens with fatigue. When we are tired, we may be unable to determine if our judgement is compromised by get-there-itis. Fortunately, we do have a cut and dried barometer of our performance that can provide a wake up call prior to a bad situation getting worse.
When you are performing up to standards, you expect to bring the airplane to a point 500 feet above the runway when in visual conditions or 1,000 feet above when in instrument conditions, on speed, on course, in a stable condition ready to land. If you somehow failed to do that, something went wrong and it might have been you.
If you are ever tempted to continue an approach which fails Stabilized Approach criteria, you might consider that you, a highly qualified and proficient pilot, somehow got the airplane into a situation it should not be. Perhaps your judgement is fatigue-impaired and you shouldn't be attempting to save a bad approach. Take it around and try it again.
Everything here is from the references shown below, with a few comments in an alternate color.
Figure: N215AA, from "Pressing the Approach", pg. 28.
Figure: Flight 1420's Approach Path, from NTSB Report, Figure 1.
[NTSB Report, pg. 1]
The captain was correct.
[NTSB Report, pg. 204 (CVR)]
The captain was obviously uncomfortable but appeared unwilling to call "knock it off" with the first officer being so willing to press on.
[NTSB Report, pg. 4]
That statement should have intuitively told both pilots it was time to go around.
The "off course" should have been a cue to go around. The actual go around call should have been made more assertively and when not executed, should have been repeated.
[NTSB Report, ¶184.108.40.206] 220.127.116.11 Use of Reverse Thrust
[NTSB Report, ¶18.104.22.168] National Aeronautics and Space Administration Study on Flight Crew Decision Errors
[NTSB Report, ¶22.214.171.124] Summary of the Flight Crew’s Performance During the Approach
[NTSB Report, ¶126.96.36.199.] American’s DC-9 Operating Manual indicated that, for landings on slippery runways, pilots were not to exceed 1.3 EPR on the “slippery portions of the runway” except in an emergency situation. Likewise, Boeing’s MD-80 FCOM indicated that reverse thrust of no more than 1.3 EPR should be used on wet or contaminated runways, except in an emergency. However, FDR evidence indicated that reverse thrust exceeded 1.3 EPR several times during flight 1420’s landing sequence.199 Further, American’s and Boeing’s maximum reverse thrust setting for landings on dry runways was 1.6 EPR, and FDR data showed that even this setting was exceeded many times during the landing.
[NTSB Report, ¶188.8.131.52.] The Safety Board’s Airplane Performance Study indicated that the accident airplane could have stopped about 700 feet before the end of the runway if the spoilers had deployed, a constant symmetrical reverse thrust at 1.3 EPR had been maintained, and the flight 1420 manual braking profile had been applied. In contrast, with the spoilers not extended, the airplane could not have stopped within the remaining runway length even if maximum manual braking had been applied immediately after touchdown and symmetrical reverse thrust at 1.3 EPR had been maintained throughout the landing roll. Thus, the Safety Board concludes that the lack of spoiler deployment was the single most important factor in the flight crew’s inability to stop the accident airplane within the available runway length.
[NTSB Report, ¶3.2] The National Transportation Safety Board determines that the probable causes of this accident were the flight crew’s failure to discontinue the approach when severe thunderstorms and their associated hazards to flight operations had moved into the airport area and the crew’s failure to ensure that the spoilers had extended after touchdown.
Contributing to the accident were the flight crew’s (1) impaired performance resulting from fatigue and the situational stress associated with the intent to land under the circumstances, (2) continuation of the approach to a landing when the company’s maximum crosswind component was exceeded, and (3) use of reverse thrust greater than 1.3 engine pressure ratio after landing.
Flight Safety Foundation, "MD-82 Overruns Runway While Landing in Proximity of Severe Thunderstorms," Accident Prevention, Vol. 59 No. 2, February 2002
Flight Safety Foundation, "Pressing the Approach," December 2006
May Day: Racing the Storm, Cineflix, Episode 2, Season 1, 3 September 2003 (American Airlines 1420)
NTSB Aircraft Accident Report, AAR-01/02, Runway Overrun During Landing, American Airlines Flight 1420, McDonnell Douglas MD-82, N215AA, Little Rock, Arkansas, June 1, 1999
Copyright 2019. Code 7700 LLC. All Rights Reserved.