PB96-910405 >

NTSB/AAR-96/05

DCA96MA008

NATIONAL

TRANSPORTATION

SAFETY

BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

COLLISION WITH TREES ON FINAL APPROACH

AMERICAN AIRLINES FLIGHT 1572

McDONNELL DOUGLAS MD-83, N566AA

EAST GRANBY, CONNECTICUT

NOVEMBER 12, 1995

. .

m *%L’bww*&*+ ‘. ‘. - .,, -. --3

6638B
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NTSB/AAR-96/05 PB96-910405

NATIONAL TRANSPORTATION

SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

COLLISION WITH TREES ON FINAL APPROACH

AMERICAN AIRLINES FLIGHT 1572

McDONNELL DOUGLAS MD-83, N566AA

EAST GRANBY, CONNECTICUT

NOVEMBER 12, 1995

Adopted: November 13, 1996

Notation 6638B

Abstract: This report explains the accident involving American Airlines flight 1572, an

MD-83 airplane, which was substantially damaged when it impacted trees in East

Granby, Connecticut, while on approach to runway 15 at Bradley International Airport,

Windsor Locks, Connecticut, on November 12, 1995. Safety issues in the report include

tower shutdown procedures, non-precision approach flight procedures, precipitous terrain

and obstruction identification during approach design, the issuance of altimeter settings

by air traffic control, low level windshear system maintenance and recertification, and

emergency evacuation issues. Recommendations concerning these issues were made

to the Federal Aviation Administration.

iii

CONTENTS

EXECUTIVE SUMMARY .................................................................. vi

1. FACTUAL INFORMATION

1.1 History of Flight ..................................................................................... 1

1.2 Injuries to Persons .................................................................................. 11

1.3 Damage to Aircraft ................................................................................. 11

1.4 Other Damage......................................................................................... 11

1.5 Personnel Information ............................................................................ 11

1.5.1 The Captain............................................................................................. 11

1.5.2 The First Officer ..................................................................................... 12

1.5.3 The Approach Controller Controlling Flight 1572 ................................ 12

1.6 Airplane Information .............................................................................. 13

1.7 Meteorological Information ................................................................... 13

1.7.1 Surface Weather Observations ............................................................... 13

1.7.2 ATIS (Automatic Terminal Information Service) “Victor” Broadcast . 14

1.7.3 Turbulence Definitions........................................................................... 16

1.7.4 WSR-88D Doppler Weather Radar Data ............................................... 16

1.7.5 Low Level Windshear Alert System (LLWAS)..................................... 17

1.7.6 NCAR Atmospheric Simulation............................................................. 18

1.7.7 SIGMETs and AIRMETs ....................................................................... 19

1.7.8 Weather Information Provided Under AAL Procedures........................ 21

1.7.9 Weather Information Received Via ACARS ......................................... 24

1.8 Aids to Navigation.................................................................................. 24

1.9 Communications..................................................................................... 24

1.10 Airport Information ................................................................................ 25

1.11 Flight Recorders ..................................................................................... 25

1.12 Wreckage and Impact Information......................................................... 26

1.12.1 Altimeter Setting Documentation........................................................... 26

1.12.2 Wreckage Distribution............................................................................ 26

1.12.2.1 Impact with Trees ................................................................................... 26

1.12.2.2 Ground Impact Information.................................................................... 29

1.12.3 Structural Damage .................................................................................. 29

1.12.3.1 Fuselage .................................................................................................. 29

1.12.3.2 Wings...................................................................................................... 30

1.12.3.2.1 Left Wing ............................................................................................. 30

1.12.3.2.2 Right Wing........................................................................................... 30

1.12.3.3 Landing Gear .......................................................................................... 31

1.12.3.4 Empennage ............................................................................................. 31
iv

1.12.3.5 Hydraulic System ................................................................................... 32

1.12.3.6 Powerplants............................................................................................. 32

1.13 Medical and Pathological Information................................................... 33

1.14 Fire .......................................................................................................... 33

1.15 Survival Aspects..................................................................................... 33

1.16 Tests and Research ................................................................................. 34

1.16.1 Systems Tests.......................................................................................... 34

1.16.1.1 Pitot-Static System ................................................................................. 34

1.16.1.2 Autopilot Systems .................................................................................. 35

1.16.1.3 Windshear Warning System................................................................... 36

1.16.1.4 Ground Proximity Warning System....................................................... 37

1.16.1.5 Other Systems......................................................................................... 38

1.17 Organizational and Management Information ....................................... 38

1.17.1 American Airlines - General .................................................................. 38

1.17.1.1 Pilot Training.......................................................................................... 38

1.17.1.2 American Airlines Single Visit Training ............................................... 39

1.17.1.3 Company Altimeter Procedures ............................................................. 40

1.17.1.4 Actions of American Airlines Since the Accident................................. 42

1.17.2 FAA Surveillance of AAL Flight Operations ........................................ 45

1.17.3 FAA Instrument Approach Design Procedures...................................... 46

1.17.3.1 Terminal Instrument Procedures (TERPS) and the VOR Approach to

 Runway 15 ............................................................................................ 47

1.17.3.2 Visual Descent Point Clearances............................................................ 49

1.17.3.3 Required Obstacle Clearance for VOR Runway 15............................... 50

1.17.3.4 Precipitous Terrain Approach Adjustments........................................... 50

1.17.3.5 VASI Obstacle Clearances ..................................................................... 51

1.18 Additional Information........................................................................... 51

1.18.1 Air Traffic Control Aspects.................................................................... 51

1.18.1.1 The TRACON Supervisor in the Tower Cab ......................................... 52

1.18.1.2 TRACON Altimeter Setting Transmissions........................................... 53

1.18.1.3 Minimum Safe Altitude Warning (MSAW)........................................... 54

1.18.2 Industry Actions to Improve the Safety of Non-precision Approaches 55

1.18.2.1 Approach Plate Terrain Depictions ........................................................ 55

1.18.2.2 Non-precision Approach Flight Procedures........................................... 55

1.18.2.3 Controlled Flight into Terrain (CFIT) Training Aids ............................ 56

1.18.2.4 Previous Recommendations on CFIT .................................................... 57
v

2. ANALYSIS

2.1 General.................................................................................................... 61

2.2 Adequacy of Weather Information......................................................... 61

2.2.1 NWS SIGMETs ...................................................................................... 61

2.2.2 Weather Conditions at BDL ................................................................... 62

2.3 Altimeter Settings................................................................................... 63

2.3.1 Other Altimeter Errors............................................................................ 65

2.4 The Descent Below MDA ...................................................................... 66

2.5 Actions After Tree Strike ....................................................................... 68

2.6 Terminal Instrument Procedures (TERPS) ............................................ 68

2.6.1 Precipitous Terrain ................................................................................. 70

2.6.2 Approach Plate Terrain Depictions ........................................................ 71

2.7 Air Traffic Control Factors..................................................................... 73

2.7.1 ATC Altimeter Setting Distribution Procedures.................................... 73

2.7.2 Tower Closure and Assistance Provided by the TRACON Supervisor 74

2.7.3 MSAW (Minimum Safe Altitude Warning)........................................... 75

2.7.4 The Outdated ATIS Broadcast ............................................................... 76

2.8 Weather Conditions at the Time of the Accident................................... 77

2.8.1 LLWAS Equipment................................................................................ 79

2.9 Survival Factors...................................................................................... 80

2.9.1 The Malfunctioning Escape Slide .......................................................... 80

2.9.2 Evacuation Route Difficulties ................................................................ 81

3. CONCLUSIONS

3.1 Findings .................................................................................................. 85

3.2 Probable Cause ....................................................................................... 90

4. RECOMMENDATIONS ..................................................................... 91

5. APPENDIXES

Appendix A--Investigation and Hearing................................................ 95

Appendix B--Cockpit Voice Recorder Transcript ................................. 96

Appendix C--Excerpt from AAL Flight Manual on Altimeter

 Setting Procedure.................................................................................. 128
vi

EXECUTIVE SUMMARY

On November 12, 1995, at 0055 eastern standard time a

McDonnell Douglas MD-83, N566AA, owned by American Airlines and

operated as flight 1572, was substantially damaged when it impacted trees

in East Granby, Connecticut, while on approach to runway 15 at Bradley

International Airport (BDL), Windsor Locks, Connecticut. The airplane

also impacted an instrument landing system antenna as it landed short of the

runway on grassy, even terrain. Flight 1572 was being conducted under

Title 14 Code of Federal Regulations, Part 121, as a scheduled passenger

flight from Chicago, Illinois, to Bradley International Airport.

The National Transportation Safety Board determines that the

probable cause of this accident was the flightcrew’s failure to maintain the

required minimum descent altitude until the required visual references

identifiable with the runway were in sight. Contributing factors were the

failure of the BDL approach controller to furnish the flightcrew with a

current altimeter setting, and the flightcrew’s failure to ask for a more

current setting.

The safety issues in the report focused on tower shutdown

procedures, non-precision approach flight procedures, precipitous terrain

and obstruction identification during approach design, the issuance of

altimeter settings by air traffic control, low level windshear alert system

maintenance and recertification, and emergency evacuation issues.

Recommendations concerning these issues were made to the Federal

Aviation Administration.
NATIONAL TRANSPORTATION SAFETY BOARD

WASHINGTON, D.C. 20594

AIRCRAFT ACCIDENT REPORT

COLLISION WITH TREES ON FINAL APPROACH

AMERICAN AIRLINES FLIGHT 1572

McDONNELL DOUGLAS MD-83, N566AA

EAST GRANBY, CONNECTICUT

NOVEMBER 12, 1995

1. FACTUAL INFORMATION

1.1 History of Flight

On November 12, 1995, at 0055 eastern standard time (EST)1

, a

McDonnell Douglas MD-83, N566AA, owned by American Airlines (AAL)

and operated as flight 1572, was substantially damaged when it impacted trees

in East Granby, Connecticut, while on approach to runway 15 at Bradley

International Airport (BDL), Windsor Locks, Connecticut. The airplane also

impacted an instrument landing system (ILS) antenna as it landed short of the

runway on grassy, even terrain. Flight 1572 was being conducted under Title

14 Code of Federal Regulations (CFR), Part 121, as a scheduled passenger

flight from Chicago, Illinois, to Bradley International Airport.

On November 10, 1995, at around 1700, the captain, first officer

and three flight attendants reported to Washington’s National Airport (DCA)

to begin a 3-day flight sequence together. The scheduled departure time was

at 1800 and consisted of three flight segments the first day from DCA to

Nashville, Tennessee, (BNA) continuing to Chicago’s O’Hare International

Airport (ORD) and to Denver, Colorado (DEN). The airplane departed DCA

at 1758, according to company records, flew the three segments, and arrived

at DEN at 0310. The crew was on duty for 10 hours and 25 minutes, and had

accumulated 5 hours and 53 minutes actual flight time. Due to the crew’s late

arrival in DEN, the regularly scheduled layover of 15 hours and 18 minutes

was reduced to 13 hours and 35 minutes.

 1

All times in this report are eastern standard time unless otherwise noted.
2

At 1615, on November 11, the flightcrew departed the hotel in

DEN for a scheduled check-in time of 1700. The airplane they were to fly

arrived late from ORD; the inbound flightcrew reported that N566AA was a

“good airplane.” Flight 1572 originated in DEN and departed there at 1809,

with the first officer as the flying pilot, arriving at ORD at 2047. The flight

was 23 minutes late, based on the scheduled arrival time of 2024. The

flightcrew stated that the airplane performed normally and that the flight was

uneventful.

Originally, flight 1572 was scheduled to depart ORD for BDL at

2125. However, due to the late arrival of connecting passengers and weather,

the flight was delayed about 2 hours. The airplane departed ORD for BDL at

2305, with the captain as the flying pilot. After takeoff, the American

Airlines dispatcher, via the Automatic Communications and Recording

System (ACARS), provided the flightcrew with updated weather and wind

conditions at BDL as part of the flight plan review message. The remark,

“PRESFR” (pressure falling rapidly)2

 was included on the weather sequence

in the message. The flightcrew reported that the flight was uneventful during

cruise, although the captain stated that he changed from a cruise altitude of

FL3

330 (about 33,000 feet) to FL350 (about 35,000 feet) to avoid an area of

turbulence. According to the captain, the flight was cleared direct to BDL

about 300 miles from the airport.

During the descent, the flightcrew received two messages over

the ACARS relating to the BDL weather. The first message was sent by

American’s dispatcher at 0030 and provided the flightcrew with the altimeter

setting of 29.23 inches Hg. that would cause the flightcrew’s altimeters to

indicate feet above field elevation (QFE), and the altimeter setting of 29.42

inches Hg. that would cause the standby altimeter to indicate feet mean sea

level (msl) (QNH) at BDL.4

 At 0031, another message was sent to the

 2

Pressure Falling Rapidly (PRESFR): A fall in pressure at the rate of 0.06

inch [Hg.] per hour which totals 0.02 inch or more.

3

Flight Level - Level of surface of constant atmospheric pressure assuming a

datum of 29.92 inches Hg., expressed in hundreds of feet; thus, if the actual atmospheric

pressure is 29.92 inches Hg., FL220 indicates exactly 22,000 feet. If the actual atmospheric

pressure is greater (or less) than 29.92 inches Hg., FL220 will be at an altitude

correspondingly higher (or lower).

4

It is AAL’s policy to set the flightcrew’s altimeters to QFE and the standby

altimeter to QNH when below 10,000 feet. Following the accident, neither crewmember
3

flightcrew by the dispatcher advising them that airplanes had been making

landings at BDL, and that those airplanes had been experiencing turbulence

and windshear on final approach.

At 0032, the airplane was instructed to descend to FL190 (about

19,000 feet) by the air route traffic control center (ARTCC) controller. Also

at that time, the cockpit voice recorder (CVR) recorded the last part of the

automatic terminal information service (ATIS) information "Victor" for BDL.

This part of information Victor gave an altimeter setting of 29.50 inches Hg.

and stated that the significant meteorological information (SIGMET) “X-ray

three” was in effect, which reported severe turbulence below 10,000 feet. At

0033, the flightcrew received further instructions from the ARTCC controller

to descend and maintain 11,000 feet and the controller announced the Bradley

altimeter setting to be 29.40 inches Hg. The flightcrew acknowledged the

altimeter setting and the clearance. As recorded on the CVR, the first officer

then listened to the entire ATIS information “Victor” message at 0034. He

then noted to the captain that the ATIS information was about 1 1⁄2 hour old.

During the descent, at 0032:23, the captain advised the flight

attendants to secure the cabin due to turbulent conditions. At 0038:45, as part

of the before-landing checklist, the first officer asked, “altimeters?” The

captain said, “twenty nine fifty.” The first officer stated, “they called twenty

nine forty seven5

 when we started down...what ever you want.” The captain

replied, “OK.” The flightcrew briefed for the VOR6

 approach to runway 15.

The CVR recorded the captain stating at 0042:48, “One seventy four’s the

elevation so, twenty nine, twenty three. Set and cross checked.” The first

officer responded, “minus uh,” to which the captain replied,

 

remembered the 0030 ACARS message or the associated altimeter settings provided them

by the company. However, papers retrieved from the accident airplane included the

ACARS message annotated with the handwritten ATIS information “Victor” that was

copied onto the ACARS message 1 minute after that message was received.

5

It is not known why the first officer announced an altimeter setting of 29.47

inches Hg. The ACARS message at 0030 gave a setting of 29.42 inches Hg., and the

ARTCC controller gave a setting of 29.40 inches Hg. at 0033. 6

Very high frequency omnidirectional radio range.
4

JEPPESEN WINDSOR LOCKS, CONN

,0

z ATIS 118.15

1

BRADLEY lNTL

RADLEY Approach (R) 125.8 3500’ 2700’ VOR Rwy 15

RADLEY Tower 120.3 t (GPS) VOR 109.OBDL

2

Ground 121.9 MSA -. BDL VOR KBDL Apt. Elev 174’

; MOIOS

Maximum holding airspeed

at Mistr Int 265 Kts.

I 2.QO D;~foN

819’0

DO. 2

---- - --------- ; ~ MISSED

, APCH FIX

,

, DODA Y ● 700’

1

I

1

7s.m 71.s0 ! $g~

1 J

.1391’

Y

:)109.0 80L -... . . . . . .

Maxi mum holding airspeed at Mistr Int 265 kts. VOR -

A4;4,:R

D::LON

i Min

1680- +328” I

3500’ p~48”- 2000’ ~ DO.2

(JJ28’) I - (182~’J ~~i<

I

5.0 I 4.a ~TDZE 172’

APT. 174’

MISSED APPROACH: Climb to 3000’ outbound via BDL VOR R-149 to DODAY [NT/

D1l. O BDL VOR and hold.

STRAIGHT. IN LANDING RWY 15 I CIRCLE. TO-LAND

.wo~(H 1080’( 900’) M.,

Kfs MOA(HI

90

1 Y, ]080’{906’:-1 YA I 10

2 Y4 140 lo81)’906,;-7~4

3 165 1080’ 906; -3

;.@ ,o**a .x,’ :.- vo ;cJ I )20 {40 160 I

Figure 1.--BDL VOR runway 15 instrument approach plate.
5

“showing seventy...check seventy7

 feet difference.” The flightcrew contacted

approach control at 0043:41 and the flight was told to “expect [the] VOR

runway [15] approach.”8

 At 0045:54, approach control instructed the flight to

descend to 4,000 feet. Approach control stated the winds were “one seven

zero at two nine gusts three nine.” A vector for the runway 15 final approach

course was then issued. (See Figure 1.) At 0049:41, the approach controller

cleared the flightcrew for the runway 15 approach. At 0049:57, he advised

the flightcrew that the tower was temporarily closed because of a problem

with one of the windows, and to report the “down time” on approach control

frequency.

According to the first officer, the flightcrew intercepted the

approach course at around 3,500 feet about 15 miles from the airport, and the

captain began configuring the airplane for landing. The captain stated that he

had the radar on the 20-mile range, observed no convective activity between

their position and the airport, and then turned the radar off. The descent and

approach were flown using the autopilot, and the CVR indicated that the

flightcrew had selected 11 degrees of flaps prior to crossing the 10 nautical

mile DME (distance measuring equipment) fix named MISTR. The captain

stated that he selected the VOR/LOC (localizer) mode for the autopilot during

the approach; however, due to the strong winds, the autopilot attempted to

apply about a 30-degree course correction and the “autopilot couldn't hold it.”

Approach control then advised the flightcrew that the airplane was left of

course. (See Figures 2a, 2b and 2c.) The captain stated that he changed the

mode of the autopilot to HDG SEL (heading select) to manually recapture the

inbound course. After crossing MISTR, the airplane was configured for

landing with 40 degrees flaps and the landing gear down. At 0051:44, the

captain began the descent to 2,000 feet using the VERT SPD (vertical speed)

mode for pitch control on the autopilot mode control panel. Two thousand

feet was the final approach fix crossing altitude. The captain stated that the

airplane encountered moderate turbulence and very heavy rain during this part

of the descent.

 7

The CVR group reported the word “seventy” to be unintelligible. The

accident flightcrew offered the word as being “seventy” after they reviewed the CVR.

8

The runway 15 approach to BDL is used primarily when the winds are such

that the speed and direction preclude the safe use of the airport’s primary runway (06/24).
6

The autopilot captured the airplane’s altitude at 2,000 feet, prior

to their arrival at the final approach fix, named DILLN, which was 5 DME

from the VOR. After passing DILLN, the captain told the first officer to set

the missed approach altitude of 3,000 feet in the flight guidance control panel

(FGCP). He began the descent to the minimum descent altitude (MDA)9

 of

908 feet above the field elevation, using the VERT SPD mode of the

autopilot. At 0054:22, the captain asked the first officer to “give me a

thousand down.”

Although the tower was temporarily closed at this time, a

TRACON supervisor was in the tower cab and communicated with the

flightcrew. (See Section 1.18.1.1 for details.) At 0054:51, the TRACON

supervisor in the tower issued a windshear alert giving winds for the

centerfield, northeast boundary, and southeast boundary of the airport. At

0055:06, the first officer stated, “there’s a thousand feet...cleared to land.” At

0055:11, he further stated, “...now nine hundred and eight is your uh...” The

captain replied, “right.”

The first officer later told investigators that he had ground

contact “straight down” and, as the airplane was “at the base of the clouds,”

he began looking for the field visually. He then looked back at his altimeter

and saw that the airplane was descending below the MDA. Following a short

period of flying through turbulence, at 0055:26.3, the first officer stated

“you’re going below your....”10 According to the captain's interview and the

flight data recorder, at this point the captain pushed the altitude hold button

for the autopilot.

According to the CVR, the “sink rate” warning was heard

approximately four seconds prior to the first impact with trees. At 0055:30.4,

the CVR recorded a sound of impact.11 The captain later stated that he then

heard a “loud report,” followed by severe turbulence.

 9

The lowest altitude, expressed in feet above mean sea level, to which

descent is authorized on final approach or during circle-to-land maneuvering in execution of

a standard instrument approach procedure where no electronic glideslope is provided.

10During a postaccident interview, the captain stated that the first officer

said, "100 below" at that time, rather than "you're going below your...."

11Investigators determined that the first impact point was with trees on the

top of a ridge line approximately 2.54 nautical miles northwest of the approach end of

runway 15.



10

According to the first officer, the captain called for a go-around and

“firewalled the throttles.” Flaps were selected to 15 degrees, and the landing

gear handle was placed in the “up” position. Both flight crewmembers

reported that the on-board windshear warning system and the ground

proximity warning system (GPWS) activated after the impact, which was

confirmed by the CVR recording. The captain stated that in a “second or

two,” the turbulence stopped, and, at 0055, according to the CVR recording,

he said to the first officer “Left motor's failed.”

The airspeed started to decrease, and the airplane began a slow

descent. The rain stopped, and the first officer saw the runway. According to

the captain, the right engine was not sustaining full thrust, and, at 0056, he

said, “Tell 'em we're goin down.” The first officer complied. The first officer

then stated to the captain, “you're going to make it,” and queried whether the

captain wanted the landing gear lowered. The first officer then selected the

landing gear to the “down” position.

The captain stated that he then called for flaps to be lowered to

40 degrees to achieve a “balloon effect” to reach the runway. The airplane

clipped the top of a tree near the end of the runway, impacted and destroyed

most of the ILS antenna array located at the end of the safety overrun area for

runway 33, and landed on the edge of the stopway. The airplane rolled down

the stopway and continued down runway 15, stopping on the runway beyond

the intersection of runway 6/24 near the tower.

An evacuation was initiated and the passengers and

crewmembers exited the airplane. The initial tree strike occurred at

approximately 41 degrees, 58.22 minutes north latitude and 072 degrees,

44.38 minutes west longitude during the hours of darkness. The ground

elevation of the first impacted tree was 728 feet above msl, and the height of

the tree where it was determined to be struck was about 770 feet msl.
11

1.2 Injuries to Persons

Injuries Flightcrew Cabincrew Passengers Other Total

Fatal 0 0 0 0 0

Serious 0 0 0 0 0

Minor 0 0 1 0 1

None 2 3 72 0 77

Total 2 3 73 0 78

1.3 Damage to Airplane

According to American Airlines officials, damage to the airplane

amounted to approximately $9,000,000.

1.4 Other Damage

According to FAA and Bradley International Airport officials,

damage to the ILS antenna array and other airport equipment amounted to

approximately $74,620.00

1.5 Personnel Information

1.5.1 The Captain

Date of birth: 07-01-56

Ratings and Certificates:

Airline Transport Pilot Certificate Number 92480401, issued 08-05-91.

Type Rating: DC-9/Airline Transport Pilot

Flight Engineer Certificate Number 92480401, issued 05-24-85

Rating: Turbojet powered/FE

Medical certificate: First Class issued 08-29-95, no restrictions

Date of hire with AAL: 04-11-85

Second in Command (SIC) time (MD80) since 09-08-86: 2,716 hours

Pilot in Command (PIC) time, (DC-9/MD80) since 08-22-91: 1,514 hours

Total flying time: 8,000 hours total, 5,000 hours civilian, 2,300 military

Total flying time last 24 hours: 10 hours

Total flying time last 7 days: 10 hours

Total flying time last 30 days: 20 hours
12

Total flying time last 60 days: 55 hours

Total flying time last 90 days: 55 hours

Last recurrent training: 08-21-95

Last proficiency check: 08-21-95

Last line check: 07-17-95

1.5.2 The First Officer

Date of birth: 11-16-56

Certificates and ratings:

Airline Transport Pilot Certificate Number 527063950, issued 08-27-88

Airplane Multiengine Land/Airline Transport Pilot

Airplane Single Engine Land/Commercial Pilot

Medical: First Class issued 03-13-95, no restrictions

Date of hire with AAL: 05-24-89

Second in Command (SIC) time, (MD-80) since 08-21-90: 2,281 hours

Total flying time: 5,100 hours total, 2,500 hours military, 2,600 hours civilian

Total flying time last 24 hours: 10 hours

Total flying time last 7 days: 13 hours

Total flying time last 30 days: 60 hours

Total flying time last 60 days: 123 hours

Total flying time last 90 days: 167 hours

Last recurrent training: 08-19-95

Last proficiency check: 08-19-95

Last line check: 08-21-90

1.5.3 The Approach Controller Controlling Flight 1572

Date of hire by FAA: December, 1991

Last Tape Talk: May 25, 1995 (no deficiencies noted)

Medical Certification: November 6, 1995 (no restrictions or limitations)

Facility records indicated that the approach controller was

current in all refresher and supplementary training. These topics included

Severe Weather, Traffic & Safety Advisories, Emergencies, Seldom Used

Procedures, Unusual Situations, Low Level Windshear, Winter & Summer

Operations, Revised MVA Video Map, various operational bulletins, and

operational error prevention bulletins. No remedial training was noted. There

was no evidence of an operational error or deviation in the past 2 years.
13

1.6 Airplane Information

N566AA, serial number 49348, is a McDonnell Douglas MD-83

twin engine transport category airplane. At the time of the accident, the total

airframe time was 27,628 hours.

Based on flight plan data, estimated fuel remaining on approach

to BDL was 15,600 pounds, and estimated landing weight was 118,360

pounds with an estimated center of gravity (CG) of 18.1 percent mean

aerodynamic chord (MAC). The allowable CG range from the MD-80

Approved Aircraft Flight Manual at 118,050 pounds is -0.8 percent to 33.4

percent.

The airplane was equipped with two Pratt & Whitney JT8D-219

turbofan engines with a normal takeoff thrust rating of 21,000 pounds and a

maximum takeoff thrust rating of 21,700 pounds. Engine times and cycles:

LEFT RIGHT

Serial Number 725677 708519

Total time (hrs) 13,014 34,681

Total cycles 7,409 19,992

1.7 Meteorological Information

The National Weather Service (NWS) Surface Analysis for

November 12 at 0100 showed a deep low (986 millibars) over Quebec with an

occluded front extending south across Eastern New York State. A secondary

low pressure center was located over New York City. There were strong

southerly winds ahead of the front and strong westerly winds behind it. A

large area of rain existed over New England.

1.7.1 Surface Weather Observations

Surface Weather Observations at BDL are made by the NWS

during the day, and a private contractor, Midwest Weather Inc., during the
14

evening hours. The following weather observations for BDL were made by

Midwest Weather:

November 11 at 2352: Record 2,200 feet scattered; measured

ceiling 2,800 feet overcast; visibility 5 miles; light rain;

temperature 61 degrees F; dew point 57 degrees F; winds 160

degrees at 28 knots gusts to 40 knots; altimeter setting 29.42

inches Hg; peak wind 160 degrees at 42 knots at 2318;

pressure falling rapidly.

The observation was transmitted to the BDL Air Traffic Control

Tower, at 2353.

November 12 at 0051: Record 1,700 feet scattered; measured

ceiling 2,800 feet overcast; visibility 3 miles; moderate rain;

temperature 61 degrees F; dew point 58 degrees F; winds 170

degrees at 25 knots gusts to 40 knots; altimeter setting 29.35;

pressure falling rapidly. Peak wind 170 degrees at 43 knots at

0018.

The observation was transmitted to the BDL control tower at

0057.

1.7.2 ATIS (Automatic Terminal Information Service) “Victor”

Broadcast

BDL ATIS recordings are created by BDL Federal Aviation

Administration (FAA) personnel and use weather information from the NWS

or Midwest Weather, depending upon the time the weather information is

formulated. ATIS broadcast "Victor," recorded at 2251, included the

information below. The next ATIS broadcast was not created until after the

accident.

Bradley Airport Information Victor zero three five one Zulu

[2251 EST]: Weather two thousand two hundred scattered,

measured ceiling two thousand seven hundred overcast,

visibility one zero, light rain, temperature six two, dew point

five seven, wind one six zero at two eight gust three niner,

altimeter two niner five zero, approach in use ILS runway two
15

four or VOR runway one five. Notice to Airmen: runway two

four and runway one five open and wet, low level windshear

advisories are in effect. Taxiway tango restricted to aircraft

with a wingspan of less than one hundred seventy one feet.

SIGMET X-ray Three is valid for severe turbulence below

one zero thousand [SIGMET X-ray Three actually noted

severe turbulence below one three thousand]. Predeparture

clearances are available, advise on initial contact you have

Victor.

ATIS Victor broadcast continually through the time of the

accident. The Air Traffic Control Handbook, FAA Order 7110.65, states that

a new ATIS recording should be made “Upon receipt of any new official

weather regardless of whether there is or is not a change in values.” The

controller responsible for updating the ATIS hourly said that he had been

planning to make a new recording but was waiting for the new weather to be

displayed on the SAIDS (Systems Atlanta Information Display System). He

said that he left the tower about midnight, and, at that time, the most current

weather conditions had not appeared on the SAIDS equipment. He did not

advise the on-coming controller that the weather had not yet appeared, and

that a new ATIS should be made. When he gave the briefing to the relieving

controller, the new weather conditions were still not available, and the

telephones to the NWS did not work. He said that in such situations,

controllers usually call the airport police station, and an officer goes across

the hall to the NWS office, which, in turn, calls the tower and relays the

weather information. He also said that this situation has occurred many times.

However, this procedure was not implemented on the night of the accident.

The relieving tower controller said that he listened to the ATIS,

but he did not notice the time on it. He did not notice if the SAIDS incoming

information warning light was blinking, which would have indicated that new

weather information was available. He said that the environment was very

noisy (wind noise), and that he heard no SAIDS incoming information

warning tones.
16

1.7.3 Turbulence Definitions

The following definitions are given in the Forecasting Guide on

Turbulence Intensity, National Weather Service Operations Manual, Chapter

D-22:

Light turbulence .. Absolute value of vertical acceleration (G)

>.2 G to .5 G.

Moderate turbulence .. Absolute value of vertical acceleration

>.5 G to 1.0 G.

Severe turbulence .. Absolute value of vertical acceleration

>1.0 G to 2.0 G.

Review of the FDR vertical acceleration trace for flight 1572

from the time of the tree strike indicates an absolute value of the maximum

change in vertical acceleration of about .5 G. The absolute value of the

maximum change in indicated airspeed is about 10 knots.

1.7.4 WSR-88D Doppler Weather Radar Data

The Velocity Azimuth Display (VAD) Vertical Wind Profile

from the Brookhaven, New York, WSR-88D radar (70 nautical miles south of

BDL) showed the following estimated values at 0055:

Height Wind Direction (degrees) Wind Speed (knots)

1,000 160 60

2,000 170 80

3,000 170 80

The VAD Vertical Wind Profile for 0051 from the WSR-88D

Doppler Weather Radar at the National Weather Service Forecast Office,

Taunton, Massachusetts (69 nautical miles east of BDL) showed:

Height Wind Direction Wind Speed

1,000 160 45

2,000 160 60

3,000 180 75
17

Estimated upper winds generated on the Safety Board's

McIDAS12 workstation, based on November 11 at 1900 upper air data,

showed the following for the BDL area:

Height Wind Direction Wind Speed

1,000 170 51

2,000 170 54

3,000 180 56

4,000 180 60

1.7.5 Low Level Windshear Alert System (LLWAS)

A Phase II LLWAS was installed and operational at BDL at the

time of the accident. The system consists of five wind sensors; one is located

at the centerfield and the other four are situated around the periphery of the

airport [northeast, northwest, southwest, southeast]. The system was

recertified on November 12, 1995, the day of the accident, and was found to

be within tolerances. According to FAA Airways Facilities personnel,

recertification involves removing each sensor from its stationary base and

then testing it to ensure it operates properly. The recertification process does

not include checking for proper alignment of the sensors on their stationary

bases.

The approximate location of the first tree strike was about 289

degrees at 1.5 nautical miles from the northwest LLWAS wind sensor, the

closest sensor to the tree strike. The following wind information was

recorded from this sensor:

Time Direction/Speed

0055:17 220/12

0055:27 214/12

0055:37 208/10

Time Direction/Speed

0056:57 215/20

0057:07 215/18

0057:17 215/16

 12McIDAS - Man Computer Interactive Data Access System. McIDAS is an

interactive meteorological analysis and data management computer system. McIDAS is

administered by personnel at the Space Science and Engineering Center at the University of

Wisconsin at Madison. Data are accessed and analyzed on an IBM PS/2 Model 77

computer.
18

0055:47 210/09

0055:57 223/06

0056:07 227/08

0056:17 225/13

0056:27 215/18

0056:37 215/21

0057:27 216/15

0057:37 210/14

0057:47 203/12

0057:57 201/10

0058:07 203/10

0056:47 214/22

FAA personnel reviewed the BDL LLWAS data from October 31

to November 12, via the FAA Site Performance Evaluation System (SPES).

The analysis indicated that the northwest LLWAS sensor was misaligned by

approximately 20 degrees.

On February 5, 1996, the Safety Board requested that the FAA

provide information on whether the alignment of the northwest sensor was

checked and whether any corrections were made. Shortly thereafter, the FAA

replied that the Weather Systems Engineering Branch, AOS-250, received the

latest LLWAS meteorological data (the analysis period was from January 13,

1996 to January 21, 1996) from BDL on February 14, 1996, and the northwest

sensor still appeared to be misaligned. A copy of all pertinent SPES data was

faxed to the airways facilities technicians at BDL on February 15, 1996, and

an inspection of the northwest sensor's anemometer alignment was performed

by certified LLWAS technicians at the airport. The anemometer was found to

be out of alignment by 38 degrees and was corrected on February 16, 1996.

The FAA indicated that the misaligned sensor did not appear to degrade the

system during the analyzed period.

According to FAA Airways Facilities personnel, the SPES

information is analyzed monthly. Misaligned LLWAS wind sensors as well

as failed components are identified and field personnel at the affected airports

are notified. However, due to staffing limitations, it may be 3 to 6 months

before the alignment of the wind sensors is physically checked by field

personnel.

1.7.6 NCAR Atmospheric Simulation

A theoretical atmospheric simulation was accomplished to

estimate the meteorological conditions that affected flight 1572 during the

approach to BDL. The simulation was performed by scientists at the National
19

Center for Atmospheric Research (NCAR). The simulation was run on a Cray

supercomputer using averaged information from horizontal increments of

about 42 meters.

The results of the simulation indicated that a pressure decrease of

about 1 millibar (1 millibar = 0.03 inch of Hg.) and downdrafts of about 400

feet per minute occurred near and to the northwest (lee side) of the ridge

where the airplane contacted the trees. The pressure decrease and downdrafts

extended to the lee side of the ridge for a horizontal distance of about 0.3

nautical miles. According to an NCAR scientist, the decrease in pressure may

have been underestimated by 2 to 3 times over distances smaller than the

horizontal resolution of the simulation. The strength of the downdrafts was

not underestimated.

1.7.7 SIGMETs and AIRMETs

The following SIGMETs13 and AIRMETs14 were applicable to

the time and route of flight of the accident airplane. They were generated by

the NWS Aviation Weather Center, Kansas City, Missouri.

AIRMET Tango was issued on November 11 at 2145 and was

valid until November 12 at 0400:

Turbulence - Moderate turbulence below 15,000 feet due to

strong winds and cold front moving across the area. Moderate

turbulence between 15,000 and 40,000 feet due to strong

winds and mid/upper level trough. Conditions mainly

southwestern half of area spreading across remainder of area

by 0400.

 13Significant meteorological information. An in-flight advisory forecast

issued by the NWS Aviation Weather Center that advises of weather (other than convective

activity) that is potentially hazardous to all aircraft. These reports cover large geographic

areas of at least 3,000 square miles.

14Airman’s meteorological information - An in-flight advisory forecast

issued by the NWS Aviation Weather Center that advises of weather (other than convective

activity) that may be hazardous to light aircraft, aircraft operating under visual flight rules

(VFR), and inexperienced pilots. AIRMETs include moderate icing, moderate turbulence,

and IFR conditions. These reports cover large geographic areas of at least 3,000 square

miles.
20

Strong Surface Winds - Sustained surface winds greater than

30 knots expected.

Low Level Windshear Potential throughout the entire area.

AIRMET Zulu was issued on November 11 at 2145 and was

valid until November 12 at 0400:

Icing - Occasional moderate rime icing in cloud between

freezing level to 20,000 feet. At 2200 freezing level 7,000 to

9,000 feet western portions of area, sloping 10,000 to 12,000

feet eastern sections.

AIRMET Sierra was issued on November 11 at 2215 and was

valid until November 12 at 0400.

IFR - Occasional ceilings below 1,000 feet and visibility

below 3 miles in precipitation and fog.

SIGMET November 2 was issued on November 11 at 1930 and

was valid until November 11 at 2330:

Moderate occasional severe rime/mixed icing in cloud and in

precipitation between 12,000 and 18,000 feet.15

SIGMET November 3 was issued on November 11 at 2235 and

was valid until November 12 at 0235:

Moderate occasional severe rime/mixed icing in cloud and in

precipitation between 12,000 and 18,000 feet. Severe mixed

reported by ATR-42 near Bridgeport at 2208 (November 11).

SIGMET X-ray 3 was issued on November 11 at 1840 and was

valid until 2240:

 15Canaan, New York, (approximate beginning of descent of flight 1572) is

about 20 nautical miles east of the eastern extent of the area outlined by this SIGMET.
21

Moderate occasional severe turbulence below 13,000 feet due

to strong low level winds. Low level windshear also

expected.

SIGMET X-ray 4 was issued on November 11 at 2240 and was

valid until November 12 at 0240:

Moderate occasional severe turbulence below 13,000 feet due

to strong low level winds. Low level windshear also

expected.

The SIGMETs and AIRMETs were not given to the flightcrew of

flight 1572 because AAL has its own meteorology department that prepares

weather information for its flightcrews.

1.7.8 Weather Information Provided Under AAL Procedures

An American Airlines meteorologist who worked the 1600 to

0000 shift on November 11 stated that a SIGMEC16 was issued for BDL

during the day on November 11, 1995, to cover low level windshear,

moderate turbulence below 8,000 feet and moderate icing in clouds and in

precipitation between 10,000 to 18,000 feet. The SIGMEC was valid from

November 11 at 1400 to November 12 at 0300 and stated:

Occasional moderate turbulence is expected below 8,000 feet

as strong winds develop during the afternoon and evening.

Low level windshear also possible. Occasional moderate

icing likely especially in the evening as widespread

precipitation approaches/develops across the area. Affected

altitudes 10,000 to 18,000 feet.

 16An FAA-approved weather product issued by AAL weather staff to support

AAL flight operations. SIGMECs are issued when weather conditions exist for moderate or

greater icing, low level turbulence, low level windshear, and/or thunderstorm activity in the

vicinity of the terminal area. The terminal area is defined as about a 25 mile radius of the

airport. En route SIGMECs are issued for significant weather conditions to include

moderate or greater icing or turbulence and thunderstorms. SIGMECs cover geographic

areas more specific to a particular AAL route of flight than do the more wide-ranging NWS

SIGMETs.
22

The SIGMEC was based upon the following weather conditions:

1. Observed surface winds 160 degrees at 28 knots with

gusts to 40 knots.

2. Observed winds aloft were between 60 to 80 knots from

the surface to 5,000 feet.

3. Surface barometric pressure was falling rapidly due to

approaching low pressure system.

4. Weather radar indicated heavy rain showers and

isolated thunderstorms approaching BDL from Long Island

Sound.

5. Numerous reports of low level windshear and moderate

turbulence were received throughout the day from heavy

aircraft in the New England area due to strong and gusty

winds.

A meteorologist who worked the 0800 to 1600 shift stated that

the SIGMEC was issued on the evening of November 11, 1995, for icing and

turbulence because of icing reports from the area of the United States from

which the weather was coming and because winds were forecast to be at an

intensity/shear level that would justify possible low level windshear and

moderate turbulence around BDL that evening. To the best of the

meteorologist's recollection, reports from larger airplanes were indicating

moderate turbulence "upstream" from the area of concern.

A meteorologist who came on duty at midnight on November 12

noted that the SIGMEC for BDL was in effect. He concluded that the

SIGMEC continued to be valid based upon meteorological information and

pilot reports available to the meteorologist. Therefore, the meteorologist

believed that no further action was required to update this SIGMEC.

The AAL meteorology staff stated that the NWS SIGMETs and

AIRMETs were not provided to flight 1572 because the AAL Weather

Services is the FAA EWINS (Enhanced Weather Information System)-

approved source of weather information. They further stated that the
23

SIGMECs generated by AAL Weather Services are an approved part of the

EWINS agreement with the FAA. SIGMECs are designed to cover adverse

weather phenomena, such as turbulence, icing and volcanic ash activity, along

a particular aircraft’s route of flight. According to the AAL meteorology

staff, NWS SIGMETs are not usually provided to flightcrews by dispatchers

because the dispatchers use the products of the AAL meteorologists rather

than the NWS and because SIGMECs provide more specific information

pertinent to the route of flight.

The dispatcher of flight 1572 stated that per AAL’s dispatcher

procedures, the flight release contained company-generated SIGMECs, but

that NWS SIGMETs were available to dispatchers by computer at the dispatch

position.

The flight release information provided by the dispatcher to the

flightcrew of flight 1572 included the terminal SIGMEC for BDL, and the

terminal SIGMEC for Syracuse, New York (SYR) issued on November 11 at

1205 valid until November 12 at 0100, stating:

Occasional moderate icing in clouds and in precipitation is

expected from 10,000 feet to flight level 18,000 feet, as

widespread precipitation develops through the afternoon.

Lower limit of icing is expected to approach surface from

west to east this afternoon as a wintery mix of precipitation

approaches the area.

Occasional moderate turbulence is also expected below 8,000

feet as strong low level southerly winds shift to strong

northerly and northwesterly winds after frontal passage. Brief

low level windshear is possible especially near the cold front.

An American Airlines En Route Turbulence Index of "2" was

indicated at flight plan altitude from top of climb to beginning of descent.

According to American Airlines meteorologists, a "2" indicates a forecast of

at most moderate chop.
24

1.7.9 Weather Information Received Via ACARS

The following weather information was transmitted to the

flightcrew during the flight via the American Airlines ACARS:

Time 2320 - BDL 2250 surface weather observation - 2,200

feet scattered, measured ceiling 2,700 feet overcast; visibility

10 miles, light rain; temperature 62 degrees F; dew point 57

degrees F; winds 160 degrees at 26 knots gusts to 35 knots;

altimeter setting 29.51 inches Hg.; peak wind 160 degrees at

35 knots; pressure falling rapidly.

Time 0030 - Weather Data as of 12/0001:

Altimeter setting 29.42 msl.

Pressure Altitude 645 feet ABV.

Conversion 29.23 Inches Hg.

Temperature 61 degrees F.

Time 0031 - Attention [captain's name] - Have information

from BDL Tower that aircraft have been making landings but

have advised of turbulence and low level windshear on final.

Winds are more aligned with runway at BOS if that becomes

necessary.

1.8 Aids to Navigation

The FAA Maintenance Management System Log Incident

Summary Listing stated that the postaccident BDL VOR flight check was

satisfactory. The Summary Listing also stated that an evaluation of technical

performance of ground equipment was completed for the BDL VORTAC,

BDL VASI, and BDL ATIS, and no problems were noted.

1.9 Communications

There were no known communications difficulties associated

with flight 1572.
25

1.10 Airport Information

Bradley International Airport is served by three paved runways.

The field elevation is 174 feet msl. Runway 6/24 is 9,502 feet long and 200

feet wide. There is an ILS CAT I and a VOR or global positioning system

(GPS) approach to runway 24 and an ILS CAT II and III, VOR, a

nondirectional beacon (NDB) or GPS to runway 6. Runway 1/19 is 5,145 feet

long and 100 feet wide. There are no instrument approach procedures

published for this runway.

Runway 15/33 (the accident runway) is 6,846 feet long and 150

feet wide, with a 998 foot unpaved safety overrun area for runway 33. There

is an ILS CAT I approach to runway 33 and a VOR (GPS) approach to

runway 15. The BDL runway 15 VOR approach is used most often when the

speed and direction of the winds preclude the use of the primary runway

06/24. The runway 15 threshold elevation is 170 feet msl and the touchdown

zone elevation is 172 feet msl. Runway 15 is equipped with high intensity

runway lights (HIRL), runway end identifier lights (REIL), and a visual

approach slope indicator (VASI)-L (angle 3.5 degrees.). The runway is

grooved.

The BDL VOR is located just north of the intersection of

runways 6/24 and 15/33. The control tower and airline terminal buildings are

located south of the intersection of runway 6/24 and 15/33.

The airport has an FAA-approved emergency plan, and it is

certificated as Aircraft Rescue and Fire Fighting (ARFF) Index D, in

accordance with 14 CFR 139.17

1.11 Flight Recorders

The airplane was equipped with a Sundstrand Model UFDR

(S/N 7605) digital flight data recorder (DFDR). It recorded 78 parameters.

 17Index D is the FAA ARFF index for air carrier aircraft of at least 126 feet

but less than 159 feet in length. 14 CFR 139 requires that a minimum of three ARFF

vehicles be available that carry an amount of water and commensurate quantity of firefighting foam so that the total quantity of water for foam production carried by all three

vehicles is at least 4,000 gallons.
26

The flight recorder tape was found undamaged with no evidence of excessive

wear. The airplane was also equipped with a Fairchild model A-100A cockpit

voice recorder (CVR) (S/N 53395). See Appendix B for a transcript of the

CVR recording that lasts 31 minutes and 29 seconds. Figures 3a and 3b

contain pertinent FDR parameters overlaid with pertinent flightcrew

comments recorded on the CVR.

1.12 Wreckage and Impact Information

1.12.1 Altimeter Setting Documentation

Following the accident, the barometric pressure settings in the

altimeters were observed to be as follows:

Captain's: 29.23 inches Hg.

First officer's: 29.23 inches Hg.

Standby: 29.47 inches Hg.

1.12.2 Wreckage Distribution

1.12.2.1 Impact with Trees

The initial impact mark from the airplane was with a tree located

on the top of Peak Mountain Ridge, approximately 2.54 nautical miles

northwest of the approach end of runway 15. Numerous additional trees also

had indications of being impacted. The ground elevation at the bottom of the

first impacted tree was 728 feet msl; the tree was determined to have broken

at 770.5 feet. The approximate location of this tree was identified by GPS

equipment as 41o

 58.22' N and 72o 44.38' W. A survey of tree heights on and

around the ridge performed shortly after the accident indicated that the trees

in the area of initial impact were approximately 60 feet tall.

Debris from the airplane and small broken tree branches were

found along the wreckage path in the wooded area on the ridge. The airplane

pieces found were leading edge skin, trailing edge flap skin, belly and flap

fairing fittings, and a clear wing tip lens cover. The right main landing gear

outboard door was also located in the wreckage path. The total length of the

wreckage path on the ridge was 290 feet. The bearing from the first to the last

impacted tree on the ridge was approximately 137o

 magnetic.


29

About 1,100 feet prior to the initial ground impact mark, a tree,

located in the flightpath of the airplane landing on runway 15, sustained a

sharp metal strike mark 76 feet above the ground. This tree was at an

elevation of about 170 feet msl.

1.12.2.2 Ground Impact Information

A total of 14 orange metal posts were fastened to 14 pairs of

concrete pads to support the localizer antenna. Post No. 13 exhibited

evidence of a black tire mark about 6 feet above the ground. Posts Nos. 3 to

12 were destroyed and were broken into numerous pieces. Three localizer

antenna posts (Nos. 1, 2 and 14) exhibited no impact damage.

The first ground scar, consisting of a black tire mark, was located

below post No. 10. This pad was approximately 18 feet to the right of

stopway centerline. A ground scrape mark progressed from below post 10

and extended toward the runway overrun area, in the direction of flight.

The left and right main landing gear tire marks crossed the

runway threshold mark on the left side. A runway threshold light (second

from the left) sustained impact damage and was found on the left side of the

runway. The left main landing gear tire marks departed the runway edge at

the threshold mark and remained on the pavement. The right main landing

gear tire mark remained inside the runway edge line. These tire marks curved

back toward the runway centerline after crossing taxiway "J". The airplane

came to rest on the runway approximately 3,137 feet from the runway

threshold.

1.12.3 Structural Damage

1.12.3.1 Fuselage

The airplane was damaged from its impact with the trees and

localizer antenna posts. There was no fire damage to the fuselage and no

impact damage to the fuselage above the floor line. No impact damage or
30

skin waviness18 was noted in the areas around the pitot tubes or static ports.

The fuselage section forward of the wing front spar had no impact damage.

The fuselage belly honeycomb fairing, aft of the wing front spar, sustained

impact damage with numerous punctures and some scrape marks from

forward to aft.

The left main landing gear forward wheel well structure, which

supports the honeycomb fairing, sustained impact damage and was bent aft.

Orange paint transfer marks were found in the area of impact. The hydraulic

lines in the wheel well just aft of the impact location were severed. The right

main landing gear forward wheel well structure was damaged and bent

slightly aft. Wood fibers were found embedded at the right main landing gear

impact location, and there were no paint transfer marks.

The lower section of the aft pressure bulkhead was crushed

radially inward. About 12 inches of structure on either side of the bulkhead

centerline were bent upwards. The main vertical beam remained intact and

was undamaged. The right side stringers were deformed slightly upwards.

1.12.3.2 Wings

1.12.3.2.1 Left Wing

The left wing remained attached to the fuselage with damage to

the leading and trailing edge control surfaces. The damage consisted mainly

of dents and tears, forming a semicircular shape, with wood fiber embedded

at the impact locations. The leading edge of the three inboard slats exhibited

impact damage at numerous locations. The trailing edge flaps remained

attached to the wing and were found extended to 40 degrees. The inboard flap

suffered damage at two locations.

1.12.3.2.2 Right Wing

The right wing remained attached to the fuselage with damage to

the leading and trailing edge control surfaces. The leading edge slats

 18Skin waviness is mild wrinkling of the fuselage skin because a skin panel

does not always conform to the exact outer mold line of an airplane. Skin waviness in the

vicinity of static ports could alter the local static pressure sensed by the ports.
31

remained attached to the wing and sustained severe impact damage. The

trailing edge flaps remained attached to the wing and were found extended to

40 degrees. The inboard flap sustained one large area of impact damage at its

inboard end, and two such areas on its outboard end.

1.12.3.3 Landing Gear

The nose landing gear was extended and remained attached to the

airplane with minor impact damage. Both nose landing gear taxi lights were

broken. Small pieces of nose landing gear taxi light glass and a retainer ring

were found on the ridge. Small tree limbs, about 8 inches long and 1 inch in

diameter were found wedged between the taxi light fixtures. Both tires

remained inflated and there was no evidence of flat spots or lateral scrape

marks on the tires.

The right main landing gear was extended and remained attached

to the airplane with impact damage to the strut scissors assembly. The

landing gear tires remained inflated. The outboard gear door was missing and

was located on the ridge. The inboard gear door remained attached and was

found in the open position.

The left main landing gear was extended and remained attached

to the airplane with minor impact damage. The outboard tire of the left main

landing gear had burst at some point in the accident sequence, and was

replaced on the runway to facilitate towing the airplane to the hangar. Small

twigs were found wedged between the tires.

1.12.3.4 Empennage

There was no evidence of any damage to the vertical stabilizer,

rudder, and rudder trim tab. The right horizontal stabilizer leading edge

contained a 3-inch-wide area of impact damage 5 feet inboard from the tip.

The damage was about 3 inches wide, and the leading edge was crushed aft.

Wood bark was found embedded in the impact location. There was no other

damage to the right horizontal stabilizer.
32

1.12.3.5 Hydraulic System

Hydraulic lines in both main landing gear wells were damaged in

the vicinity of other wheel well structural damage. On the forward wall of the

left main landing gear well, the left system ground service and power transfer

suction lines were broken. In addition, a brake return line near the control

module was bent and leaking. In the right wheel well, several lines were

broken between the brake control module and the landing gear.

1.12.3.6 Powerplants

Both engines had tree branches and sticks in the inlets. The fan

blades on both engines had soft body impact damage and wood fibers were

found on the underside of the mid-span shrouds. The left engine cases and

fan ducts did not have any holes or penetrations, and the fourth stage turbine

blades were intact. The right engine fan duct and intermediate case were

burned in the plane of the seventh and eighth stage compressor stages;

however, the cowling was not burned. The forward side of the mixer lobes

and struts had metal spatter build up. The right engine did not have any other

apparent damage.

Internal examination of the engines revealed that the left engine

low pressure compressor (LPC) stages were damaged due to the impact of the

rotors with the stators, particularly in the third stage area. The high pressure

compressor (HPC), high pressure turbine (HPT), and low pressure turbine

(LPT) were not damaged, but they had metal spatter on the airfoil surfaces.

The right engine LPC stages were also damaged due to the impact of the rotor

with stator airfoils. The HPC seventh, eighth, and ninth stage blades were

burned, almost down to the airfoil platforms. Metal spatter was found on the

HPT and LPT airfoils. The fuel controls and fuel pumps were bench tested

and found to be working correctly.

The flight data recorder engine pressure ratio parameters

indicated that the engines were operating at engine pressure ratios of about

1.5 at the time of the ridge line tree strike. No mention of engine problems

prior to the ridge line tree strike were noted upon review of the cockpit voice

recording.
33

1.13 Medical and Pathological Information

Shortly after the accident, both flight crewmembers underwent

standard drug testing. The results of these tests were negative.

1.14 Fire

See Section 1.12.3.6 for description of fire damage to the right

engine.

1.15 Survival Aspects

According to interviews with the flight and cabin crewmembers,

after the airplane stopped, the captain ordered an evacuation. A flight

attendant opened the aft emergency exit/galley door, but the slide did not

inflate automatically, as intended. He pulled the manual inflation handle, and

the slide then inflated. An unknown number of passengers and two flight

attendants evacuated through this exit.

Because the evacuation slide failed to inflate automatically, it

was examined by investigators from the Safety Board, American Airlines, and

the FAA at the facilities of the manufacturer, Air Cruisers Company.

Three tests were conducted on the airplane’s emergency

evacuation slide assembly. The first two tests followed the Douglas

maintenance manual instructions which did not call for the inflation cable to

be routed through the grommet on the girt bar grommet tab. The instructions

stated, “check that loop on firing lanyard is secured to girt tab with retaining

ring on manual inflation handle; then secure lanyard cover flap over firing

lanyard.” In those two tests, the slide dropped down but did not unfold or

inflate. In the first test, the manual inflation handle remained within view

when the door was opened, and within reaching distance of the cabin door. In

the second test, the handle dropped over the side of the fuselage, and it could

not be seen from the cabin by someone standing at the door. In the third test,

the inflation cable was routed through the grommet on the girt bar grommet

tab. When it was tested, the slide inflated properly.

In July, 1996, McDonnell Douglas incorporated revised text and

graphics on the installation of floor level emergency evacuation slides into the
34

FAA-approved MD-80 and DC-9 maintenance manuals. That revision

instructs the installer to “[p]ass [the] inflation cable19 loop through [the]

grommet tab,” and includes two diagrams illustrating the proper routing of the

inflation cable through the grommet tab.

According to the flight attendants and questionnaires that

passengers provided to the Safety Board, during the evacuation, flight

attendants shouted commands to passengers to remove their shoes (regardless

of shoe style) and to leave carry-on luggage on the airplane. About a third of

the passengers who completed questionnaires stated that shoe removal either

slowed their evacuation or that shoes in the aisle obstructed their exit.

Passengers (including a woman carrying a 10-month old baby) reported that

they stumbled or tripped over piles of shoes in the aisle and galley areas.

American Airlines is the only major air carrier that commands

passengers to remove all shoes during an evacuation.

1.16 Tests and Research

1.16.1 Systems Tests

1.16.1.1 Pitot-Static System

The airplane was equipped with three pitot-static systems. The

captain's system provides inputs to digital central air data computer (CADC)

No. 1, which drives the captain's primary flight instruments (Mach/airspeed

indicator, vertical speed indicator, and altimeter). The first officer's system

provides inputs to CADC No. 2, which drives the first officer's primary flight

displays. The third system, known as the auxiliary system, provides inputs

directly to the standby altimeter and airspeed indicator. Each system has its

own pitot probe and static ports.

 19In the revised text and graphics, the term “inflation cable” is sometimes

used in place of the previously used term for the same part, “firing lanyard.” However, the

term “firing lanyard” is still used to designate that part in several diagrams and unchanged

portions of the maintenance instructions for removal and installation of evacuation slides.
35

Following the accident, an atmospheric leak check was

performed on all three systems in accordance with the AAL Maintenance

Manual. According to the test procedure, the maximum allowable changes in

altitude and airspeed during the test are 100 feet and 5 knots in 1 minute (i.e.,

leakage in the system may not result in more than 5 knots airspeed deviation

or 100 feet difference in altitude). All three systems successfully passed this

test.

An additional test was performed to determine the relative

accuracy of the pitot static systems. All three systems were tested at

simulated approach flight conditions, and the cockpit airspeed and altitude

readings were recorded. Indications from all three sets of flight instruments

were within 25 feet and 3 knots of each other at all flight conditions tested.

The CADCs have a self-test capability. Both computers

successfully passed this test. In addition, it was noted that the magnetic fault

indicators (fault balls) on the computers were not tripped.

The heater elements in the pitot probes and static ports were

tested and found to be functioning properly.

1.16.1.2 Autopilot Systems

The airplane was equipped with two autopilot systems, each

controlled by a digital flight guidance computer. In the vertical axis, the

autopilots can fly the airplane through various flight maneuvers such as

maintaining an existing altitude and climbing or descending to a preselected

altitude and holding that altitude. Selection of modes is done through the

flight guidance control panel.

Following the accident, the E-24 circuit breaker (DC Autopilot 1)

was found tripped in the cockpit. It could not be determined when the circuit

breaker tripped. During systems group testing, electrical power was applied

to the airplane, and the E-24 circuit breaker was reset. It remained in for the

duration of the testing without tripping.

An autoland preflight test, normally initiated during the

autoflight portion of the daily preflight, was performed after the accident, and

both autopilot systems successfully passed this test. Further, a return-to-
36

service test, normally performed by maintenance personnel following

replacement of an autoflight system component, was also accomplished, and

both systems successfully passed this test.

Several additional tests were performed to evaluate the effect of

the E-24 (DC Autopilot 1) circuit breaker on Autopilot 1 system operation.

With the system engaged, tripping the circuit breaker caused the blue AP 1

engagement lights on the flight mode annunciators to go out and the red

flashing AP DISCONNECT lights to illuminate. In another test, it was

determined that if the circuit breaker was already tripped, Autopilot 1 would

not engage.

Following the accident, the flight guidance system of an

American Airlines MD-80 simulator was used to capture a VOR course on a

VOR instrument approach and to establish rates of descent using the vertical

speed mode of the autopilot. Prior to the final approach fix (FAF) for the

VOR instrument approach, altitude capture was accomplished using the

altitude select window. After passing the FAF, altitude capture was

accomplished using the altitude hold button on the flight guidance panel.

With manual capture of altitude, using the altitude hold button, a

vertical speed of 1,100 feet per minute, and the "rough air" feature of the

simulator activated, the rate of descent was simulated. When the altitude hold

button was engaged, the simulator continued to descend an additional 120 to

130 feet. The simulator then recovered, or climbed back up to, the selected

altitude. In simulated smooth air, the simulator recovered with less total loss

of altitude. For example, with rate of descent of 700 feet per minute, when

altitude hold was engaged, the loss and recovery took about 50 feet.

Similarly, with a rate of descent of 1,100 feet per minute, a recovery from

about 80 feet below the desired altitude occurred.

1.16.1.3 Windshear Warning System

The airplane was equipped with a Honeywell Standard

Windshear System, which is designed to provide warnings to the flightcrew in

the event of a potentially hazardous windshear condition. The computer

activates yellow caution lights if it detects an increasing performance

windshear, and it activates red warning lights and an aural "WINDSHEAR,

WINDSHEAR, WINDSHEAR" warning if it detects a decreasing
37

performance windshear. A successful self-test of the windshear warning

system was performed in accordance with the AAL Maintenance Manual.20

1.16.1.4 Ground Proximity Warning System

The airplane was equipped with an Allied-Signal Mark II Ground

Proximity Warning System (GPWS) computer. This computer utilizes a radio

altimeter21 and barometric altitude rate information to determine proximity

with the ground. The GPWS is designed to activate electronically produced

word warnings and visual light warnings to warn the flightcrew when a

hazard is detected.

The system operates in several modes to provide warnings for

various unsafe flight conditions. These modes include: excessive descent

rate, excessive terrain closure rate, descent after takeoff, descent in wrong

configuration, and excessive deviation below the glideslope.

During a non-precision approach, with the airplane configured

for landing (gear and flaps down), the only mode available is excessive rate of

descent warning. In this mode, the computer monitors barometric sink rate

beginning with the airplane descending below 2,450 feet (agl). If the sink rate

exceeds a threshold value, a "SINK RATE" aural warning is issued. At

approximately 200 feet (agl), the threshold value is approximately 1,200 feet

per minute. According to the CVR transcript, the "SINK RATE" warning is

heard 4 seconds before the sound of the first impact with the trees.

A ground proximity warning system (GPWS) ground test was

performed according to the AAL Maintenance Manual. The test was

successfully completed, and all annunciations and aural warnings operated

normally.

According to Allied-Signal, development is underway on an

upgraded GPWS system known as Enhanced GPWS. This system

 20During the accident sequence, the windshear warning system did not

activate until just after the ridge line tree strike occurred.

21A radio altimeter, sometimes called a radar altimeter, does not require

accurate barometric pressure settings, but rather gives readouts of height above the ground

by time-varying frequency and by measuring differences in frequency of received waves,

proportional to time and height.
38

incorporates aircraft position data (from the flight management system) with a

self-contained terrain database to offer enhanced protection from descent into

terrain. On a non-precision approach, the enhanced GPWS can anticipate the

terrain features within a 25 mile radius of the airport and offer warnings to

protect against premature descent into terrain, regardless of airplane

configuration. This system is expected to be certified by the FAA for use in

aircraft in 1996.

1.16.1.5 Other Systems

The follow-up rod that drives the left flap position sensor was

bent and damaged. It was not possible to determine how this damage would

have affected the flap position indication. During the initial on-scene

investigation, the flap track indicators showed that the flaps were in the 40

degree position. No anomalies were seen during flight control cable tension

tests. All six fuel boost pumps were tested and found to operate normally. A

DME functional/accuracy test was performed, and no problems were noted.

1.17 Organizational and Management Information

1.17.1 American Airlines - General

1.17.1.1 Pilot Training

The American Airlines McDonnell Douglas MD-80 fleet is in

applicant status for the Advanced Qualification Program (AQP).22

Accordingly, pending development/completion of the AQP, pilot

qualification, including training and certification, is conducted under the

terms of Exemption Number 5950, which grants relief from some of the

traditional pilot qualification requirements of 14 CFR Part 121. For example,

the FAA grants permission to perform a single visit training (SVT) session,

which is once per year training, to any carrier that applies to develop an AQP,

while the AQP development is in progress (see Section 1.17.1.2). The AQP

 22The Advanced Qualification Program is described in Special Federal

Aviation Regulation (SFAR) 58. The purpose of the AQP is to “provide for approval of an

alternate method for qualifying, training, certifying, and otherwise ensuring competency of

crewmembers, aircraft dispatchers, other operations personnel, instructors, and evaluators

who are required to be trained or qualified under Parts 121 and 135 of the FAR....”
39

development process may take 2 or more years to complete for each airplane

type. American Airlines applied for approval of an AQP in April 1994 for

SVT on all its airplanes, beginning with the Fokker F-100. Once the AQP has

been approved by the FAA, pilot qualification will be conducted in

accordance with the AQP requirements of SFAR Number 58. At that time,

Exemption Number 5950 will no longer be applicable.

1.17.1.2 American Airlines Single Visit Training

Single Visit Training differs from traditional FAR Part 121

training and checking requirements in that it is conducted annually for

captains and first officers rather than bi-annually. A training session every 6

months, as opposed to every 12 months under SVT, is conducted only for

initial upgrade captains, captains who fail a SVT proficiency check, or

captains who require additional training. Single visit training consists of onsite ground and flight training/checking for a 4- or 5-day period. Two days of

the recurrent ground training cover security, crew resource management,

aircraft systems, performance and emergency equipment review. Two 4-hour

simulator sessions are scheduled with specified briefing and debriefing

periods. The first simulator is a practice session overseen by a simulator pilot

to review and practice required maneuvers. The second 4-hour simulator

session, overseen by a check airman, includes a recurrent line operated

simulation (LOS)23 period followed by an annual proficiency check for both

flight crewmembers.

The FAA approved Exemption 5950 for AAL based upon a SVT

training plan with certain conditions and limitations. One of the limitations

imposed upon AAL is that the airline must include a pretraining "first-look"

evaluation that addresses at least a core set of Part 121, Appendix F,24

material prior to the repeated execution of any such core set items in a

simulator or training device. The maneuvers, tasks, or procedures are those

most likely to be sensitive to loss of proficiency because of infrequency of

 23Line operational simulation (LOS) is the FAA’s revised terminology for

training that was formerly known as line oriented flight training (LOFT), and includes

special purpose orientation training and line operational evaluation. The revised definition

(FAR Part 142.3) was adopted on May 23, 1996, and became effective on August 1, 1996.

24Appendix F sets forth maneuvers and procedures required to be

demonstrated in pilot proficiency checks.
40

practice. Data on the first look maneuvers is provided to the FAA on a deidentified basis.

The MD-80 Worksheet, dated February 1995, included four

items designated as "first-look" maneuvers. One of the first-look maneuvers

is the non-precision approach. Further, AAL requires this non-precision

approach to be included in the first-look evaluation in all the fleet training

programs that AAL operates. The captain completed American Airlines 4-day

SVT on August 21, 1995. The first officer completed SVT training on August

19, 1995. Both flight crewmembers received satisfactory performance reports

during their training.

1.17.1.3 Company Altimeter Procedures

AAL is the only United States airline that uses the QFE (height

above field elevation) altimeter setting system during the takeoff, departure,

approach, and landing phases of flight.25 American Airlines procedures

require flightcrews to set their primary altimeters so that they read altitudes

above the elevation of the airport they are departing from or at which they are

arriving, while the standby altimeter continues to show altitude above sea

level. Other U.S. airlines use the QNH (height above sea level) altimeter

setting system during all flight phases. These airlines set all their altimeters to

show altitudes above sea level at the departure and arrival airports. During

the cruise phase of flight, all airlines use the QNH altimeter setting method.

The details of American Airlines QFE altimeter setting methodology follow.

During a descent, AAL procedures call for the flightcrew to set

the proper QNH altimeter settings in both the primary altimeters (the

captain’s and the first officer’s) and the standby altimeter located on the

center instrument panel. This is to be accomplished when passing down

through the flight level 180 (in the United States). After reaching the AAL

"changeover altitude" (10,000 feet), the flightcrew is to set the captain's and

first officer's altimeters to a QFE setting so that they read height above

 25The former Eastern Airlines also used the system in its operations.

Currently, several foreign carriers use the system in international operations. There are

certain airports within the AAL system with very high field elevations that require the pilot

to use only QNH (height above sea level) altimeter settings during approaches. Mechanical

limitations within the altimeters preclude the adjustment of the altimeters to satisfy QFE

requirements.
41

destination field elevation. As a cross-check to ensure that the companyprovided QFE setting is accurate, a comparison should then be made between

the altitude shown on the flightcrew’s altimeters and that shown on the third

standby altimeter containing the QNH (height above sea level) setting. The

difference, in feet, between the flightcrew's altimeters and the standby

altimeter should equal the published elevation of the airport of intended

landing.

During descent and prior to arrival at the final approach fix

(FAF), AAL procedures require the flightcrew to use the standby altimeter

with the QNH setting for intermediate air traffic control or approach plate

directed level-offs. According to AAL procedures, upon arrival at the FAF,

the flightcrew should begin using their primary altimeters which are set QFE.

If a missed approach is commenced, the flightcrew should revert to the

standby altimeter (QNH) for altimeter information.

After landing, AAL flightcrews’ primary altimeters should read

zero feet. Flightcrews of airlines that use the QNH system, on the other hand,

should see altimeters that read the field elevation of the airport after landing.

According to many AAL flightcrews, one advantage of the QFE

system over the QNH system is the standardization of approaches with regard

to altitudes seen by flightcrews from the FAF until landing. This is especially

true, they said, during ILS approaches that usually have minimum altitudes of

200 feet above the ground. Most approaches flown by AAL flightcrews are

ILS approaches. Regardless of the field elevation above sea level, flightcrews

become accustomed to using 200 feet above the ground as a minimum

altitude. Each approach, no matter what the airport elevation, will appear the

same to flightcrews, concerning minimum altitude.

According to the AAL DC-9 Operating Manual, the following

mandatory altitude callouts are to be made by the pilot not flying during an

approach to land:

1. 1,000 feet above field level

2. 100 feet above minimum descent altitude (MDA)

3. MDA
42

The first officer, who was the pilot not landing, called out:

“There’s a thousand feet” at 0055:06 The flight recorders revealed that this

one thousand foot callout was made when the primary altimeters indicated

that the aircraft was about 1,140 feet above the field elevation, based upon the

altimeter setting of 29.23 (QFE). The CVR does not reflect a callout at 100

feet above MDA.

1.17.1.4 Actions of American Airlines Since the Accident

On December 20, 1995, 38 days after the accident involving

AAL flight 1572, AAL flight 965, a regularly scheduled passenger flight from

Miami, Florida, to Cali, Colombia, struck terrain near Buga, Columbia, 33

miles northeast of the Cali (CLO) VOR navigation aid, in night visual

meteorological conditions, during a descent for a landing at Cali. The

airplane was destroyed, and 159 of 163 passengers and crewmembers aboard

lost their lives. The Colombian civil aviation authority determined that the

probable causes of that accident were:

1. The flightcrew’s failure to adequately plan and execute

the approach to runway 19 at [the airport] and their

inadequate use of automation.

2. Failure of the flightcrew to discontinue the approach into

Cali, despite numerous cues alerting them of the

inadvisability of continuing the approach.

3. The lack of situational awareness of the flightcrew

regarding vertical navigation, proximity to terrain, and the

relative location of critical radio aids.

4. Failure of the flightcrew to revert to basic radio

navigation at the time when the FMS-assisted navigation

became confusing and demanded an excessive workload

in a critical phase of flight.

Contributing to the cause of the accident were:

1. The flightcrew’s ongoing efforts to expedite their

approach and landing in order to avoid potential delays.
43

2. The flightcrew’s execution of the GPWS escape maneuver

while the speedbrakes remained deployed.

3. FMS logic that dropped all intermediate fixes from the

display(s) in the event of execution of a direct routing.

4. FMS-generated navigational information that used a

different naming convention from that published in

navigational charts.26

Discussions between FAA and AAL officials in early January

1996 led to AAL’s formation of a Safety Assessment Program to examine

seven critical phases of American’s operations. AAL plans to have quarterly

progress meetings and issue a final report in January 1997. AAL also

implemented immediate actions after the accident that included raising the:

1. minimum descent altitude and visibility requirements for

all non-precision approaches by 100 feet and 1/2 mile,

respectively,27

2. visibility minima on all NDB approaches by 1 statute

mile, and

3. the ceiling of the “sterile cockpit” from above 10,000 feet

to above 25,000 feet in Latin American airspace.

On January 19, 1996, AAL distributed to all of its DC-9 captains

and first officers DC-9 Operating Manual Bulletin No. DC-9-2 (in the form of

additional checklist pages) entitled “Non-Precision Approach Crew

Coordination Procedures.” The bulletin states, in part:

Despite its name a non-precision approach must be executed

with exacting precision.

 26Aircraft Accident Report, “Controlled Flight Into Terrain, American

Airlines Flight 965, Boeing 757-223, N651AA, Near Cali, Colombia, December 20, 1995.”

Aeronautica Civil of the Republic of Colombia.

27These restrictions have since been eliminated following the completion of

other phases of the Safety Assessment Program.
44

MDAs and step-down altitudes are limits. Any altitude leveloff variation must be above the MDA or step-down altitude

rather than below [italics in original bulletin].

The primary attention of both pilots will be directed to the

level-off at the step-down altitude or MDA.

After level-off at the MDA, the pilot-not-flying will direct

primary attention outside the airplane and call out visual

references in the sequence required.

AAL’s examination of its operations was to be carried out

through seven assessment teams, each with representatives of the airline, the

pilot’s union and the FAA. The seven areas addressed by these teams are:

1. Human factors issues pertaining to the recent accidents,

including approach charts, procedures, and training;

2. Division-specific items, dealing with issues relevant to

unique geographic features;

3. Advanced technology relating to flight management

system (FMS) and GPWS modifications;

4. Operations structures and procedures, including corporate

culture or organizational influences on flight operations;

5. Flight Operations Quality Assurance (FOQA), and

evaluation of its implementation in conjunction with AAL’s

“Airline Safety Action Partnership” (ASAP) program to

improve training in general for feedback into the Advanced

Qualification Program (AQP);

6. Confidential reporting system data analyses; specifically,

examination of all available information, and assess any new

and useful techniques from other operators for accident

prevention; and
45

7. Pilot communications, including visits by the Senior Vice

President, Flight Operations, and the President, APA, to meet

all pilots and flight managers at all crew bases.

In addition, AAL established a Controlled Flight Into Terrain

(CFIT) Task Force and a Non-Precision Approach Working Group. It also

inserted specific guidance on flightcrew response to CFIT scenarios in the

Advanced Aircraft Maneuvering Program. All AAL simulators now have

specific terrain profiles in which flightcrews will receive GPWS terrain

warnings and are expected to extract maximum aircraft performance in

recovery. The airline briefed the Safety Board at the 6 month or midpoint of

its Safety Assessment Program and has reported that the assessment

program’s report is expected to be completed on schedule in January 1997.

1.17.2 FAA Surveillance of AAL Flight Operations

The FAA conducted a National Aviation Safety Inspection

Program (NASIP) inspection of AAL from August 21 through September 1,

1995. Both airworthiness and operations were inspected. One area of

potential deficiency noted involved operations training. Specifically, it was

found that AAL broke up crew pairs in the SVT training program, contrary to

the terms of Exemption 5950 and the AAL Approved Training Manual. A

crew pair consists of a captain and a first officer. Both documents state that

pairs of crewmembers should remain together as much as possible through all

phases of training and checking. During the NASIP inspection, 35 cockpit en

route inspections were performed. Those en route inspections resulted in no

findings concerning flight operations.

The captain had been observed by FAA flight inspectors during

four en route inspections. FAA records indicated that the captain does not

have an accident/incident or violation history.

There is no record of FAA en route inspections for the first

officer. FAA records indicated that the first officer does not have an

accident/incident or violation history.
46

1.17.3 FAA Instrument Approach Design Procedures

In the past, the FAA instrument procedures development

personnel were collocated with Flight Inspection Area Office (FIAO)

personnel, and, in fact, served as copilots on FIAO flight inspection missions.

Following the loss of a Beech Super King Air 300/F flight inspection airplane

near Front Royal, Virginia, on October 26, 1993, the Safety Board issued

Safety Recommendation A-93-165 to the FAA on November 24, 1993.

Subsequently, the procedures development program was separated from the

flight operations inspection program. Safety Recommendation A-93-165

asked the FAA to:

Direct the Office of Aviation System Standards to evaluate

the recommendations in the 1989 System Safety Survey

relating to the second-in-command responsibilities and flying

proficiency and to establish duties as appropriate.

The Administrator responded to this recommendation by stating:

On February 5, 1995, all procedures development duties were

removed from the second-in-command (SIC) position

description, and SIC duties are restricted to flying

responsibilities.

FAA Terminal Instrument Procedures (TERPS) Handbook, FAA

Order 8260.3B, contains standardized methods for designing instrument flight

procedures for non-precision approaches. The development and final

approval of a non-precision instrument approach is accomplished in several

steps. First, the basic procedure is developed by the National Flight

Procedures Office in Washington, D.C. (AVN-100) in coordination with the

nearest regional Flight Procedures Office (FPO) to the airport where the

approach is to be used. Once developed, the procedure is sent to the

Technical Support Branch, AVN-160, for a quality control review. After the

review, the procedure is sent to the Flight Inspection Operations Division,

AVN-200, through the FIAOs, to ensure that the descents and turns on the

approach are within realistic flight inspection tolerances. AVN-200 is also

responsible for ensuring that obstacles marked on the chart are actually where

they are depicted, and that the obstacles are as high as the chart depicts.
47

According to the FAA, the FIAO is responsible for final approval

of instrument flight procedures by ensuring that:

(1) Data used to develop the instrument approach procedure

was correct.

(2) The instrument approach procedure was developed in

accordance with FAA Order 8260.3B TERPS and Order

8260.19 [C], Flight Procedures and Airspace, and other

appropriate directives....

In reference to obstacle data accuracy, paragraph 270 of FAA

Order 8260.19 states:

The evaluations can provide accurate, consistent, and

meaningful results and determinations only if FIAO and

regional flight procedures specialists apply the same rules,

criteria, and processes during development, review, and

revision phases.

The National Flight Procedures Office (AVN-100) uses maps,

charts, surveys and mathematical data to develop the basic approach

procedure. The FIAOs under AVN-200 use airplanes, theodolites (optical

devices to measure angles and thus heights), and other direct measuring

equipment for obstacle height verification.

The Atlantic City, New Jersey, Flight Inspection Area Office

(FIAO), initially verified the height of the obstacles on the BDL VOR runway

15 approach as it was being developed. This office also rechecked the

obstacles after this accident. On both occasions, the FIAO determined that

the approach was “obstacle free.”

1.17.3.1 Terminal Instrument Procedures (TERPS) and the VOR

Approach to Runway 15

The instrument approach to runway 15 was first published and

became effective on February 9, 1989. The controlling obstacle in the final

segment (the highest obstacle that could affect the approach) was 739 feet of
48

terrain and an additional 8028 feet tree height, for a total height of 819 feet

msl. This is the ridge line and trees that the flight 1572 initially struck.

Amendment 1 to the procedure was effective on the same date,

February 9, 1989. The amendment revised the missed approach point (MAP)

from a point defined by time and distance to one based upon the BDL VOR.

Amendment 2, effective on July 20, 1995, included several

changes to the procedure. One change included the addition of a visual

descent point (VDP) to the approach. A VDP is defined as a point on the final

approach from which normal descent from the MDA to the runway

touchdown point may be commenced, provided that visual reference is

established. The VDP was 3.1 nautical miles from the BDL VOR, which is

2.86 nautical miles from the threshold of the runway.

On April 8, 1994, the Air Line Pilots Association (ALPA) sent a

letter to the Manager of the Flight Procedures Review Branch in the FAA’s

New England Region. In part, the letter stated that several pilots had

experienced GPWS warnings while descending from the 5 nautical mile FAF

to the 3.1 nautical mile VDP. ALPA stated that the steep nose-down attitude

might have been exacerbated by the close proximity in that segment of the

ridge line struck by flight 1572.

In the summer of 1994, as a result of ALPA’s concerns, an

analysis of the VDP was undertaken by the FAA. The FAA procedures

analyst indicated that a “no-VASI” standard (3 degree descent angle) had

been used in the VDP placement, thereby placing the VDP at 3.1 nautical

miles from the VOR. This is 0.6 nautical mile farther away than the VDP

would have been located using a “with-VASI” standard (3.5 degree descent

angle). Because a 3.5 degree VASI was already on runway 15 at BDL, it was

determined that the VDP located according to a no-VASI 3 degree descent

standard should not have been published, and it was removed by Amendment

 28Although FAA standards specify 60 feet as an acceptable tree allowance in

the Connecticut area, the procedures specialist stated that he retained the original 80 foot

value (used when the approach was first designed) to provide an added safety measure. It

could not be determined why the 80 foot value was used when the approach was first

designed. The exact height of the trees struck by the airplane could not be determined

because the tops were torn into many small pieces.
49

2A. Amendment 2A was the latest amendment to the procedure, and it was

the chart used by the accident flightcrew.

1.17.3.2 Visual Descent Point Clearances

According to the TERPS Handbook 8260.3B, paragraph 251a, 1)

where a VASI is installed, the VDP shall be located at the point where the

lowest VASI glideslope intersects the lowest MDA. The Handbook also

states, “Do not establish a VDP if penetrations of the VDP surface exist....”

Based on the downwind bar of the runway 15 VASI at 3.0 degrees, a VDP

would be placed at around 2.5 DME. TERPS criteria also require a 2 degree

obstacle clearance surface for the installation of the VDP.

On June 26, 1996, as a result of this accident, the Safety Board

made the following recommendations to the FAA:

A-96-31

Publish a visual descent point (VDP) for runway 15 in the

appropriate location, and ensure that the VDP is present on all

VOR runway 15 instrument approach charts used by pilots

flying into Bradley International Airport (BDL).

A-96-32

If the inclusion of a VDP on approach charts to runway 15 is

not possible due to obstacles, because charting methodology

rather than empirical measurement was used to determine

obstacle clearance, then ensure that a warning about the 3.5-

degree glideslope and the high terrain along the approach path

is placed on VOR runway 15 instrument approach charts for

BDL, or make such a warning a permanent Notice to Airmen

(NOTAM) for BDL, or use some other means to disseminate

such a warning on a permanent basis.

On September 4, 1996, the FAA responded favorably to Safety

Recommendation A-96-31 by stating that:

The Federal Aviation Administration (FAA) agrees with this

safety recommendation and on August 15, 1996, published a

visual descent point (VDP) at 2.3 nautical miles (BDL 2.4
50

DME) on the VOR RWY 15 instrument approach procedure

for Windsor Locks/Bradley International Airport,

Connecticut.

Because of this response, Safety Recommendation A-96-31 is

being classified “Closed--Acceptable Action,” and A-96-32 is being classified

“Closed--No Longer Applicable.”

1.17.3.3 Required Obstacle Clearance for VOR Runway 15

According to TERPS Handbook, FAA Order 8260.3B, the

required obstacle clearance (ROC) for VOR approaches with final approach

fixes is 250 feet rounded to the next higher 20-foot increment. Using this

criteria, the 819 foot msl ridge line results in 1,080 feet msl ROC (908 feet

agl). Because no adjustments were deemed necessary by the FAA for the

VOR runway 15 approach, this number is also used as the MDA.

1.17.3.4 Precipitous Terrain Approach Adjustments

The forward of TERPS Handbook, FAA Order 8260.3B, states:

This publication prescribes standardized methods for use in

designing instrument flight procedures....These criteria do not

relieve procedures specialists and supervisory personnel from

exercising initiative or taking appropriate action in

recognizing both the capabilities and limitations of aircraft

and navigational aid performance.

Paragraph 323 of that handbook pertains to minimums’

adjustments. Paragraph 323 (a) states that consideration should be given to

induced altimeter errors and pilot control problems in precipitous terrain that

may result when winds are 20 knots or more over such terrain. TERPS

Handbook, FAA Order 8260.3B does not, however, define precipitous terrain.

According to the FAA, the flight procedures specialists do not

automatically add adjustments to ROCs for precipitous terrain. Rather, they

rely on flight inspection reports and user inputs. According to the BDL air

traffic control tower personnel, there have never been any complaints or

comments regarding the effect of the ridge line on altimeters or its effect upon
51

airplane control on the approach course to runway 15. The FAA did not

adjust the BDL VOR runway 15 approach MDA for precipitous terrain.

1.17.3.5 VASI Obstacle Clearances

BDL has a VASI-4 system for runway 15. The upwind bar is

aimed at 3.5 degrees and the downwind bar is aimed at 3.0 degrees. FAA

Order 6850.2A, paragraph 301b, states that the VASI should have a clear 2

degree obstacle clearance surface originating at the VASI downwind bar and

extending to 4 nautical miles.

In 1987, the FAA’s New England Region, Airways Facilities

Branch, had the obstacle clearance surface checked by survey and it was

validated “clear” of obstacles. On November 13, 1995, the day after the

accident, a flight inspection of the approach was conducted by the Atlantic

City Flight Inspection Area Office. The flight inspection form reports that the

VASI was checked satisfactory for obstacle clearances.

During the initial development of the BDL VOR runway 15

approach, the procedures specialist that designed the approach determined,

based upon charts, that a 55-foot obstruction existed within the required

obstacle clearance plane of the VASI. In June, 1996, the FAA responded to

Safety Board requests about obstacle clearance relative to the VASI,

indicating that the 819-foot obstruction on the ridge line penetrated the

required 2 degree clearance surface by 55 feet.

1.18 Additional Information

1.18.1 Air Traffic Control Aspects

The BDL TRACON provides separation and sequencing to

arriving and departing airplanes at Bradley International Airport. The BDL

tower controls takeoffs and landings at BDL. The accident occurred during a

late evening shift. The normal staffing at that time (and the actual staffing at

the time of the accident) for BDL TRACON is one area supervisor and one

full performance level (FPL) radar controller. The control tower cab is

normally staffed with one FPL controller on late evening shifts.
52

1.18.1.1 The TRACON Supervisor in the Tower Cab

Because of high winds on the night of the accident, one of the

windows in the BDL air traffic control tower began to flex and water began to

leak inside the tower cab. A decision was made to temporarily close the tower

and the TRACON Area Supervisor in Charge made notifications of tower

closure to the New England Communications Center and airport management.

He then asked the Bridgeport automated flight service station (AFSS) to issue

a NOTAM [Notice to Airmen] concerning tower closure. He then ensured

that local and ground control frequencies, normally handled by local and

ground controllers in the tower, were being monitored in the TRACON.

The TRACON supervisor then escorted the airport carpenters to

the tower cab to inspect the windows, and he saw that the window closest to

the local control position appeared to be bowing more than the others. He

noted water at the bottom seal. The carpenters determined that the window

could be fixed and then departed the tower. The TRACON supervisor

remained in the tower cab, and then told the approach controller, located in

the radar room beneath the tower cab, that if he wanted to put flight 1572 on

the tower frequency it would be fine because "I'm up here and this way if I

need to tell him anything, I can."

The TRACON controller and the TRACON supervisor in the

tower were not providing air traffic control services to other airplanes at the

time. The approach controller then told American Airlines flight 1572 that

there was “someone in the tower,” that while it was “not really officially

open,” the flight could change to tower frequency. Flight 1572 proceeded to

do so.

At 0053:27, flight 1572 transmitted, "Hey, tower American

Airlines flight 1572 we're on a six-mile final for runway one five." The

TRACON supervisor in the tower cab transmitted to flight 1572, "landing is

at your discretion, sir. The winds 170 at 25, peak gusts 40, and ah the runway

does appear clear, you can land and taxi to the gate at your discretion." At

0054:51, the TRACON supervisor transmitted:
53

Windshear alert. Uh, centerfield one seven zero at two five.

The uh, northeast boundary, one seven zero at two four, one

niner zero at twelve at the southeast boundary.

Flight 1572 responded with, “Copy.” About 1 minute later, at

0056:02, flight 1572 transmitted, “Tower, call for emergency equipment...,

we’re going down on the runway.” At 0056:25, the TRACON supervisor

issued the wind as 170 degrees at 22 knots. Flight 1572 then transmitted

again to call for emergency equipment, and the supervisor stated that the

equipment was inbound. About 10 seconds later the airplane touched down.

The TRACON supervisor had been a full performance level

tower controller 3 years previously, and he also possessed a current

multiengine commercial pilot's license with an instrument rating, and a flight

instructor's certificate. His total flying time was about 670 hours.

1.18.1.2 TRACON Altimeter Setting Transmissions

The controllers in the tower and the TRACON obtain current

altimeter information from the DASI (Digital Altimeter Setting Indicator).

The DASI system is a self-contained instrument located in the tower’s

equipment room, and it transmits the current altimeter to readouts located in

both the tower and TRACON. In turn, the reading on the DASI is used to

update the automated radar terminal system (ARTS) so that the altitude

readouts on the controllers’ radar displays are correct. The ARTS system

always reads in msl. According to air traffic control procedures in the ATC

Handbook, FAA Order 7110.65, the altimeter setting should be transmitted to

the flight upon initial radio contact.

The ARTS record of keyboard entries shows that at 0021:14, the

approach controller entered 29.38 inches Hg. in the ARTS systems area of the

computer. The record of entries further shows that at 0044:34 he entered

29.34 inches Hg., and at 0048:07, he entered 29.36 inches Hg. The

atmospheric pressure continued to drop and was calculated to be 29.24 inches

Hg. at the time of the accident.

Boston ARTCC issued flight 1572 an altimeter setting of 29.40

inches Hg. at 0033:30, about 21 minutes prior to the tree strike, and

approximately 11 minutes before handing the flight off to the BDL TRACON.
54

This was the last altimeter setting issued to the flight from an air traffic

controller. The TRACON approach controller did not issue a current

altimeter setting to flight 1572 upon initial radio contact with the flight at

0043:49. At that time, the DASI readout indicated a setting of 29.38 inches

Hg.

A review of the BDL Facility Status Logs from October 1, 1995,

through November 11, 1995, revealed no reports of outages or complaints

concerning the tower’s DASI.

1.18.1.3 Minimum Safe Altitude Warning (MSAW)

MSAW is a computer program to warn a controller when an

airplane descends or will descend below a predetermined altitude. The

MSAW at BDL was programmed to provide an alarm if the aircraft’s Mode C

transponder transmitted two signals when the airplane was at or below 1,050

feet msl. However, if the radar does not pick up the aircraft’s mode C

transponder signal, the program cannot function. The BDL approach control

radar system produced an MSAW alarm for flight 1572 at 0055:39. The radar

tracking data showed that when this alarm was produced, the aircraft was at

800 feet msl and the aircraft had already struck the trees. FAA personnel

stated that under normal circumstances, the MSAW should have produced an

audible alarm at that time in the tower cab, and a visual alarm should have

occurred on the radar display and on the DBRITE [bright radar indicator

tower equipment] in the radar room and tower cab.

Radar tracking data showed no radar "hits" from flight 1572’s

mode C transponder between 0055:23 and 0055:32, and also none between

0055:05 and 0055:23. The radar antenna produces returns about every 4.5

seconds. FAA personnel reported that the reason for the absence of these hits

was the shielding of the airplane from the radar by the ridge line. FAA

technicians later explained that if the radar could not "paint" the airplane, the

MSAW computer program could not warn the controller that the airplane was

at an unsafe altitude.

According to FAA equipment design personnel, if a steady

stream of Mode C information had been available to the computer, the

MSAW alarm would have sounded as soon as the aircraft descended past

1,100 feet msl. They indicated that on final approach, a standardized set of
55

MSAW parameters is used, not taking into account obstacles such as the

ridge. BDL FAA personnel said that in an attempt to improve radar coverage

prior to the accident, they had changed or optimized the tilt on the radar

antenna, but that the ridge still obstructed radar coverage.

1.18.2 Industry Actions to Improve the Safety of Non-precision

Approaches

1.18.2.1 Approach Plate Terrain Depictions

The Safety Board reviewed several other airlines’ BDL VOR

runway 15 approach plate terrain depictions. This review revealed that the

information provided to the flightcrews varied among the carriers. The

British Airways approach chart for the BDL VOR to runway 15 (published by

Aerad) had terrain contours depicted in color. The ridge line and the

associated 819 foot obstruction was depicted on the approach chart.

The Delta Air Lines approach plate for runway 15 included an

additional information sheet depicting terrain along the approach from

MISTR to DILLN and the airport. The 819 foot obstruction and the ridge line

were depicted on the supplement.

The other approach charts reviewed by the Safety Board were

similar to the one used by AAL in that they contained only a notation of the

819 foot obstacle, but they did not depict the ridge line.

1.18.2.2 Non-precision Approach Flight Procedures

To reduce the glidepath variability that may occur in nonprecision approaches (as opposed to precision approaches with constant

glidepaths) some airlines are devising methods to fly non-precision

approaches in ways that more closely resemble precision approaches.

In airplanes that have modern flight management system suites,

some airlines are recommending that their flightcrews fly a stabilized

approach with a constant glidepath to a point near the MDA. In other words,

flightcrews are to overfly intermediate level-off points at higher altitudes,

while maintaining a stable rate of descent, rather than fly down to

intermediate level-off points, level off, then descend again to reach the next
56

lowest altitude authorized by the approach procedure. To ensure that

flightcrews do not descend below the MDA using the new stabilized approach

technique, one airline adds an additional 50 foot safety buffer to the MDA to

allow the airplane to "round out" its descent above the actual MDA before a

missed approach climb is established.

1.18.2.3 Controlled Flight Into Terrain (CFIT) Training Aids

The Boeing Commercial Airplane Group, as part of a larger

aviation industry effort to prevent CFIT accidents, has produced a five-part

CFIT Education and Training Aid for use by all operators. Section One of the

aid gives top managers of airlines a broad overview of the CFIT problem and

possible solutions. Section Two, a Decision Maker’s Guide, describes areas

of line airline operations, whereby those who regulate and lead the aviation

industry can aim their efforts toward CFIT elimination. Section Three is an

Operator’s Guide describing specific causal factors of CFIT accidents, traps in

which flightcrews can find themselves, and specific in-flight escape

maneuvers. Section Four describes a model CFIT education program for an

airline, and Section Five provides further background information on the

CFIT problem via selected readings and topical accident and incident

information.

The Flight Safety Foundation (FSF)-sponsored CFIT Task Force

has developed a CFIT checklist to aid in the avoidance of CFIT accidents.

This checklist was created to identify the degree of potential for a CFIT

accident prior to each flight. The checklist user evaluates risk factors

associated with a particular flight by assessing the relative danger of each risk

factor and the safety-enhancing aspects of the proposed flight in a numerical

fashion. The checklist is divided into two diagnostic parts:

CFIT Risk Assessment (includes negative destination CFIT

risk factors such as VOR/DME approaches, airports near

mountainous terrain, and radar coverage limited by terrain

masking, and risk multipliers such as IMC [instrument

meteorological conditions] weather and long crew duty days).

CFIT Risk Reduction Factors (includes positive company

management traits and the availability of CFIT training

programs).
57

Within the highest set of CFIT risk factors, according to the FSF,

are flying at night in IMC conditions, and using the autopilot in the vertical

speed mode close to the ground.

1.18.2.4 Previous Recommendations on CFIT

The Safety Board has made many safety recommendations to the

FAA concerning CFIT accidents and GPWS during the last 25 years. The

first recommendation, A-71-053, concerned a Southern Airways DC-9 that

struck power lines on approach to the Gulfport, Mississippi Municipal

Airport. The FAA responded that existing instrumentation and procedures

were safe and adequate to prevent these accidents provided cockpit disciplines

were maintained. However, CFIT accidents continued to occur, and in 1975

the FAA made GPWS mandatory on Part 121 airplanes. In 1986 the Safety

Board asked FAA to extend GPWS coverage to Part 135 operations. FAA

studied the issue, and made GPWS mandatory on Part 135 turbine-powered

airplanes with 10 or more passenger seats in 1994. The Board has also issued

numerous recommendations on improving GPWS equipment and flightcrew

training over the years.

The catastrophic losses of life and property from CFIT accidents

have not been restricted to Parts 121 and 135. In 1995, the Board

recommended that coverage be extended to all turbojet aircraft with 6 or more

passenger seats, including Part 91 operations. The Department of

Transportation (DOT) recently released a study29 for the FAA on Part 91

turbine-powered aircraft that shows a “significant potential for CFIT accident

prevention in the aircraft fleet studied.” FAA staff have informed Safety

Board staff that the FAA is preparing a notice of proposed rulemaking

(NPRM) that would require enhanced GPWS on all Part 91, 121, and 135

aircraft that are turbine powered with 6 or more passenger seats.

 29DOT report, “Investigation of Controlled Flight Into Terrain, Aircraft

Accidents Involving Turbine-Powered Aircraft with Six or More Passenger Seats Flying

Under FAR Part 91 Flight Rules and the Potential for Their Prevention by Ground

Proximity Warning Systems,” Project Memorandum #DOT-TSC-FA6D1-91-01, by Robert

O. Phillips, March, 1996.
58

After the investigation of the AAL Cali, Columbia, accident, the

Aeronautica Civil of the Republic of Colombia made the following

recommendations to the FAA:

Require that all approach and navigation charts used in

aviation graphically portray the presence of terrain that is

located near airports or flightpaths.

Encourage manufacturers to develop and validate methods to

present accurate terrain information on flight displays as part

of a system of early ground proximity warning. (Enhanced

GPWS)

Develop a mandatory CFIT training program that includes

realistic simulator exercises that are comparable to the

successful windshear and rejected takeoff training programs.

Evaluate the CFIT escape procedures of air carriers operating

transport category aircraft to ensure that the procedures

provide for the extraction of maximum escape performance,

and ensure that those procedures are placed in operating

sections of the approved operations manuals.

The Aeronautica Civil of the Republic of Colombia made the

following CFIT recommendation to the International Civil Aviation

Organization:

Evaluate and consider the adoption of the recommendations

produced by the CFIT Task Force that have been created

under the initiative of the Flight Safety Foundation.

Following the investigation of the AAL Cali, Columbia, accident,

the Safety Board made the following recommendations to the FAA on

October 16, 1996:
59

A-96-93

Evaluate the terrain avoidance procedures of air carriers

operating transport-category aircraft to ensure that the

procedures provide for the extraction of maximum escape

performance and ensure that those procedures are placed in

procedural sections of the approved operations manuals.

A-96-94

Require that all transport-category aircraft present pilots with

angle-of-attack information in a visual format, and that all air

carriers train their pilots to use the information to obtain

maximum possible airplane climb performance.

A-96-95

Develop a controlled flight into terrain training program that

includes realistic simulator exercises comparable to the

successful windshear and rejected takeoff training programs

and make training in such a program mandatory for all pilots

operating under 14 CFR Part 121.

A-96-98

Develop and implement standards to portray instrument

approach criteria, including terminal environment information

and navigational aids on FMS-generated displays, that match,

as closely as possible, the corresponding information on

instrument approach charts.

A-96-101

Examine the effectiveness of the enhanced ground proximity

warning equipment and, if found effective, require all

transport-category aircraft to be equipped with enhanced

ground proximity warning equipment that provides pilots with

an early warning of terrain.

A-96-102

Require that all approach and navigation charts graphically

present terrain information.
60

A-96-106

Revise Advisory Circular 120-51B to include specific

guidance on methods to effectively train pilots to recognize

cues that indicate that they have not obtained situational

awareness, and provide effective measures to obtain that

awareness.
61

2. ANALYSIS

2.1 General

The flightcrew had the proper FAA airmen certifications and

were qualified in accordance with applicable regulations and company

requirements. They received the proper amount of crew rest before the

accident flight and did not appear to be under unusual psychological pressure.

The airplane was properly fueled; passengers and cargo were loaded in

accordance with AAL weight and balance requirements. The flight was

released in accordance with AAL dispatch procedures.

The weather at BDL was at or above the required minimums for

landing, and included overcast clouds, visibility restricted by moderate rain,

and strong, gusty wind conditions. All components of the VOR runway 15

instrument approach were operating normally. No malfunctions of the visual

approach slope indicator (VASI) for runway 15 were reported by the airport.

There was no evidence of a malfunction of the pitot-static

system, the autopilot system, the ground proximity warning system, the

windshear warning system, or any flight control system, that could have

contributed to this accident. In addition, no structural failures occurred prior

to the airplane striking trees. According to the FDR and postaccident

examination, the left engine rolled back to a low power level shortly after the

ridge line tree impact due to low pressure compressor damage. The right

engine continued to operate at a high power setting until a fire burned away

the high pressure compressor airfoils. Both engines were operating normally

prior to the tree strike.

2.2. Adequacy of Weather Information

2.2.1 NWS SIGMETs

There were a number of NWS SIGMETs in effect pertinent to

the route of flight 1572. These SIGMETs were not included in the flight

release or provided to the flightcrew while en route to BDL by American

Airlines dispatch. However, the flight release of flight 1572 included an

American Airlines Terminal SIGMEC for moderate turbulence, moderate

icing, and low level windshear for the BDL area. Severe icing or turbulence
62

was not forecast by American Airlines' meteorological staff, although the

NWS meteorologists were forecasting occasional severe turbulence and icing

in a larger area that included the route of flight for flight 1572.

The Safety Board concludes that, regarding the operation of

flight 1572, AAL weather forecasts, as documented in the SIGMECs, were

substantially correct. NWS SIGMETs covered broader geographic areas than

the more focused AAL SIGMEC reports, and contained, in this case,

information on occasional severe icing and turbulence that did not apply to

flight 1572. The Safety Board also concludes that AAL’s FAA-approved

system of providing flightcrews with more focused forecasts, in the form of

SIGMECs, is a valid method of weather dissemination. Should a flightcrew

be forced to divert to an area not covered by a SIGMEC forecast, ample

opportunity exists, via ACARS or air-to-ground radio, to obtain current

weather in the divert area. In addition, providing flightcrews with both

SIGMECs and SIGMETs might prove confusing to flightcrews when the

reports are inconsistent, as they were in this case.

2.2.2 Weather Conditions at BDL

The National Center for Atmospheric Research (NCAR) study

conducted for this investigation stated that the predicted pressure decrease of

1 millibar could be underestimated by a factor of 2 or 3. The Safety Board

concludes that such an underestimation did not occur at the time of the

accident because the FDR altitude trace did not contain an altitude spike that

would have resulted from a significant atmospheric pressure change.

The flightcrew was given the BDL weather conditions prior to

departure that forecast strong winds, moderate turbulence and possible low

level windshear during their time of expected arrival. After takeoff, the first

officer stated that they received a normal ACARS message that included a

2300 BDL weather observation. The message also stated that the pressure

was falling rapidly (PRESFR).

During the descent, the flightcrew received two messages over

the ACARS relating to the BDL weather. The first message was sent at 0030

and provided the flightcrew with the altimeter setting for conversion to an

above field elevation (QFE) setting and the altimeter setting for mean sea
63

level (QNH) at BDL. At 0031, another message was sent to the flightcrew

advising them of turbulence and windshear on final approach.

At 0034, the first officer received the ATIS information for BDL,

and he recognized that it was “over an hour and a half old.” However, the

flightcrew did not request more current information about the conditions at

BDL. Interviews revealed that both flight crewmembers were aware of the

turbulence and windshear advisories at the field. They were also aware of the

possibility of a low but legal ceiling and visibility. The CVR revealed that

they made appropriate preparations with the lead flight attendant regarding

the passengers and cabin service in preparation for approach and landing in

turbulent conditions. They were also aware that the tower was closed due to

wind damage.

Although it would have been prudent to request a weather update

from the BDL final approach controller, the Safety Board concludes that with

the exception of a current altimeter setting (discussed below), the flightcrew

had adequate information concerning the weather at BDL as they began their

descent to the airport.

2.3 Altimeter Settings

The altimeter settings (29.42 inches Hg. (QNH) and 29.23 inches

Hg. (QFE)) received by the flightcrew in the 0030 ACARS message were

based upon a 2352 weather report. Thus, these altimeter settings were 29

minutes old when the flightcrew received them and 54 minutes old when the

airplane struck the trees on the ridge line. The altimeter setting they received

from Boston Center at 0033:27 (29.40 inches Hg.) was 22 minutes old when

they struck the trees. The altimeter setting they received in the ATIS message

at 0034 (29.50 inches Hg.) was based on a 2251 recording of the weather, and

was 1 hour and 46 minutes old when the tree strike occurred.

About the time of the accident the correct QFE altimeter setting

for the airport was about 29.15 inches Hg. Using this value, the Safety Board

concludes that the indicated altitude (height above airport elevation) that the

airplane’s QFE altimeter was indicating was about 76 feet too high (based on

the altimeter setting received at 0030), resulting in the airplane being 76 feet

lower than indicated on the primary altimeters.
64

The Safety Board concludes that because they knew that the

atmospheric pressure was falling rapidly, the flightcrew should have

requested a current altimeter setting from the BDL approach controller when

one was not given by the controller, as required, upon initial radio contact. If

they had done so, they would have received a current altimeter setting of

29.38 inches Hg. (QNH) which would most likely have resulted in the aircraft

being 40 feet higher30 than it was when it struck the trees, or approximately 71

feet above the terrain. The survey of tree heights that was performed shortly

after the accident indicated that trees in the area of initial impact were

approximately 60 feet tall. Therefore, an additional 40 feet might have given

the aircraft enough clearance to miss the trees on the downslope of the ridge.

Accordingly, the Safety Board concludes that the flightcrew’s failure to

request a current altimeter setting from the approach controller was a

contributing factor in this accident.

AAL procedures require that the flightcrew change the primary

altimeters from QNH (height above sea level) to QFE (height above the

ground) during the descent at 10,000 feet. To accomplish this, flightcrews use

either the QNH and QFE settings obtained from AAL ground station

personnel at the airport of intended landing or they use both settings from

company meteorologists obtained over ACARS. In this case, the flightcrew

received an ACARS message at 0030 that contained a QFE setting of 29.23

inches Hg. and a QNH setting of 29.42 inches Hg. According to AAL

procedures, the flightcrew should have then set their individual altimeters to

QFE and compared them to the third (standby) altimeter that would still be set

to QNH. The difference between the two settings should be equal to the

published field elevation of the airport of intended landing.

After the accident, the primary altimeters were found set at 29.23

inches Hg., which is consistent with the setting given in the ACARS message.

However, the standby altimeter was set at 29.47 inches Hg., which does not

match the setting found in the ACARS message, or with any of the other

altimeter settings given to the flightcrew. During the descent, the first officer

stated to the captain that 29.47 inches Hg. (QNH) was what had been given to

them when they started to descend. In fact, the Boston ARTCC had given,

and the first officer acknowledged, a setting of 29.40 inches Hg. (QNH).

 309.25 feet for each 0.01 inch of Hg. between 29.38 and 29.42.
65

If the flightcrew had set the altimeters to 29.23 (QFE) and 29.42

(QNH) the settings would have produced the proper difference in indicated

altitudes, which would have been equal to the field elevation (174 feet msl).

Although the flightcrew used an incorrect standby altimeter setting during the

initial descent below 18,000 feet, the mistake could have been detected if the

proper procedures31 had been used at the changeover altitude of 10,000 feet.

First, when the pilots switched from using the standby altimeter to determine

their altitude, set in error at 29.47 (QNH), to their primary altimeters, set at

29.23 (QFE), their altimeters displayed an indicated altitude that was about

240 feet lower than the standby altimeter. Second, using the QFE setting of

29.23 inches Hg. given the flightcrew by the 0030 ACARS message, the field

elevation would have been inconsistent with any altimeter setting on the third

altimeter, except the setting of 29.42 inches Hg. (QNH).

Following the accident, neither crewmember stated that they

remembered the ACARS message or the associated altimeter settings that the

company provided to them. However, documents retrieved from the accident

airplane revealed that the ATIS information was handwritten on the ACARS

message received from the company. The Safety Board could not determine

who wrote this information on the message. However, the Safety Board

concludes that, although the flightcrew did not use the most current QNH

setting they had available in the standby altimeter (29.40 inches Hg.), this

error did not affect the accident sequence of events because the flightcrew had

the correct, but outdated, QFE setting (29.23 inches Hg.) in the altimeters they

were using when the accident occurred.

2.3.1 Other Altimeter Errors

Safety Board investigators determined that there were two

potential sources of altimeter errors in addition to the incorrect altimeter

setting already discussed. They are (1) the error resulting from differences

between the true mean temperature of the column of air below the airplane

and the mean temperature assumed for the air column in the standard

atmosphere; and (2) the error associated with departure of the distribution of

 31AAL procedures require flightcrews to compare the differences between

the primary and standby settings to the field elevation. If there is a discrepancy, they would

be expected to read the ACARS message again for the correct settings, or, most effectively,

to ask the approach controller for a current setting.
66

pressure from hydrostatic equilibrium.32 The effect of errors resulting from

these two sources was found to be insignificant in this case.

2.4 The Descent Below MDA

According to the AAL DC-9 Operating Manual the pilot not

landing is responsible for calling out 1,000 feet above field level, 100 feet

above minimum descent altitude (MDA), and MDA.

The first officer, who was the pilot not landing, called out:

“There’s a thousand feet” at 0055:06. A correlation of the CVR with the FDR

revealed that this 1,000-foot callout was made at around 1,140 feet agl, based

upon the flightcrew’s altimeter setting of 29.23 inches Hg. (QFE). Although

this mandatory callout was made, the first officer did not follow additional

company procedures by also calling out 100 feet above MDA (1,008 feet

above the field elevation). However, 5 seconds later, at 0055:11, the first

officer stated to the captain, “now nine hundred and eight is your uh...,”

which indicated that he was aware of the close proximity of the MDA (908

feet agl) to the 1,000 above field level callout. At that time, the airplane was

about 1,050 feet agl. The captain replied, “right.”

The first officer stated that he then looked out the airplane

windshield to locate the airport. When he looked back at the instrument

panel, he saw that the airplane had descended below MDA. At 0055:25, the

first officer said, “You’re going below your....” At that time the airplane was

about 350 feet above the ground and 5 seconds away from contact with the

trees. Information from the DFDR indicates that a constant rate of descent of

1,100 feet per minute was maintained until the first officer uttered his “you’re

going below your....” statement. The Safety Board concludes that if the first

officer had monitored the approach on instruments until reaching MDA and

delayed his search for the airport until after reaching MDA, he would have

been better able to notice and immediately call the captain’s attention to the

altitude deviation below the MDA.

 32Hydrostatic equilibrium is a balance between gravity and pressure gradient

force. Strong winds flowing over high terrain can result in nonhydrostatic equilibrium.
67

Further, if the flightcrew had computed a visual descent point

(VDP) for their approach to runway 15, as described in the AAL flight

manual, the DME associated with a VDP would have provided the flightcrew

with a specific point in space to leave the MDA for landing. There would be

no reason for the first officer or the captain to be looking away from the

instruments and out the windscreen for the airport until just before or at the

VDP. Both of them could have been concentrating upon the level off at the

MDA. However, in this case, no VDP was calculated, the first officer began

looking for the airport prior to reaching the MDA in the critical stages of the

descent to MDA, and he was not adequately monitoring the flight instruments

to serve as an additional backup to the captain.

If the captain had planned for a VDP, he could have set up a

more shallow rate of descent commensurate with reaching the target altitude

at or just prior to the VDP. The reduced rate of descent would have allowed

the captain to better monitor his descent progress toward the MDA. Also, a

reduced rate of descent would have enabled the airplane to capture the MDA

with less of a roundout (altitude loss) when the autopilot altitude hold button

was depressed. A reduced rate of descent would also have given the captain a

greater opportunity to arrest the descent at the MDA if he had manually taken

control of the airplane.

The captain stated that he attempted to “level off” the airplane at

MDA, using the altitude hold button of the autopilot. However, that feature

of the autopilot was not engaged until after the first officer uttered his “you’re

going below your....” statement. The captain never took manual control of the

airplane to either arrest his descent at the MDA or to initiate a more positive

and immediate recovery to the MDA once he flew below this altitude.

In summary, regardless of the outdated altimeter setting that

affected the indicated altitude that the flightcrew observed, they allowed the

airplane to descend about 309 feet below the indicated MDA for the

instrument approach. The captain initially did not recognize the descent

below MDA, and he failed to react immediately when he was alerted to the

altitude deviation by the first officer. The Safety Board concludes that the

flightcrew’s failure to maintain the required MDA until the required visual

references identified with the runway were in sight directly caused this

accident.
68

2.5 Actions After Tree Strike

Regardless of the fact that the flightcrew descended below the

MDA, their actions after the initial tree strike were noteworthy. The leading

edge and trailing edge flaps of the airplane were severely damaged, power

from one engine failed almost immediately after the tree strike, and power

from the other engine failed shortly thereafter. Any mistakes in glidepath

management, ground track management, or airplane configuration timing by

the captain and first officer would probably have caused the airplane to land

in unsuitable terrain prior to the clear area at the end of the runway and

undoubtedly would have resulted in more severe injuries to crew and

passengers. The Safety Board concludes that the excellent crew resource

management and flight skills that the flightcrew used, as reflected on the CVR

recording following their encounter with the trees, were directly responsible

for limiting the number of injured passengers to one individual.

2.6 Terminal Instrument Procedures (TERPS)

As discussed below, the manner in which AVN-100 procedures

specialists evaluated the obstacles on the instrument approach in question is

markedly different from that of the flight procedures inspectors in the FIAO,

making it possible to come to a different conclusion concerning the height of

obstacles along the flightpath. In spite of the procedures that required the

FAA FIAO to coordinate with the flight procedures specialists in the event of

data or charting errors, such coordination apparently was never effectively

accomplished.

The instrument procedures development program was separated

from the flight operations inspection program in 1994. The procedures

specialists, who design the instrument approaches, are now part of the FAA’s

Office of Aviation System Standards (AVN) and design an approach based

upon charting methodology, rather than actual physical surveys to determine

obstacle clearance surfaces. The specialists never directly measure obstacle

heights, glidepath angles, and other variables, when they design an approach,

but rather they rely upon graphs, charts, maps, and tables of information to do

so. During the initial development of the BDL VOR runway 15 approach, the

procedures specialist that designed the approach determined, based upon

charts, that a 55 foot obstruction existed within the required obstacle

clearance plane of the VASI. Further, if a VDP were to be established at the
69

intersection of the VASI with the MDA, the same obstruction would penetrate

the required obstacle clearance plane by 55 feet. This was inconsistent with

the FIAO determination, both during the approach development and after the

accident by means of flight inspection, that the obstacle clearance plane was

not penetrated by the ridge line and trees.

Order 8260.19C, paragraph 430, states, in part:

Establish a VDP on a non-precision approach, providing the

[standard instrument approach procedure] SIAP meets the

requirements of TERPS....

But, paragraph 432, further states, in part:

If a VDP is not established, give the reason; e. g., obstacles....

An examination of FAA records revealed no reason for the

absence of a VDP for the approach to runway 15 at BDL.

If the VASI geometry designed by the procedures specialist

indicated an encroachment by obstacles of 55 feet, then FAA procedures

should have required re-examination of the approach to determine the

adequacy of clearance, and the VASI should have been moved or

decommissioned until the required obstacles were removed. If, on the other

hand, the VASI obstruction clearance plane was “clear,” then in the Safety

Board’s opinion, an appropriately located VDP should have been placed on

the approach plate to provide flightcrews with an appropriate DME fix from

which a visual descent for landing could be made more safely. Based upon

TERPS criteria for VDP location, the DME fix for the VDP should have been

located on the flightpath past the ridge line and trees. This would provide

flightcrews with adequate required obstacle clearance and a defined point

from which a visual descent could be made, past the ridge line. It would also

tend to keep approaching airplanes at a safer altitude until after passing the

ridge line where they would begin their descents to the MDA.

The flight procedures unit used maps, charts, surveys and

mathematical data to support their conclusions, whereas the flight inspection

unit used airplanes and a theodolite (an optical device to measure angles and

heights) for obstacle height verification. In this case their results were
70

different with regard to the height of the trees on the ridge line and whether

they constituted an obstruction within the VASI-required obstacle clearance

plane. The different methods of verification can be a good check and balance

to ensure accuracy of measurements; however, when the two branches

differed in conclusions, there should have been, but was not, a mechanism in

place to resolve the differences. The Safety Board concludes that quality

control was inadequate within the FAA for accurately resolving the height of

the trees on the ridge line. Therefore, the Safety Board believes that the FAA

should examine and make more effective the coordinating efforts of the flight

inspection program and the procedures development program, with emphasis

placed on ensuring quality control during the development, amendment, and

flight inspection process for instrument approaches.

The Safety Board also concludes that there is great value in

flying non-precision approaches with a constant rate or angle of descent until

the airport environment can be visually acquired, if the avionics aboard the

airplane can safely support such a procedure. Therefore, the Safety Board

believes that the FAA should evaluate TERPS design criteria for nonprecision approaches to consider the incorporation of a constant rate or

constant angle of descent to MDA in lieu of step-down criteria.

2.6.1 Precipitous Terrain

The TERPS Handbook states that consideration should be given

to induced altimeter errors and pilot control problems in precipitous terrain

that may result when winds are 20 knots or more over such terrain. No

changes to the instrument approach procedure for runway 15 at BDL were

made to account for precipitous terrain. Precipitous terrain is not defined in

the TERPS Handbook. However, the BDL runway 15 approach is used

primarily when the winds are such that their speed and direction preclude the

use of the primary runway 06/24. Such conditions are likely to result in wind

velocities in excess of 20 knots over the ridge line, which occurred the night

of the accident. Such winds adversely affect airplane altimetry, and although

it does not appear to have been a factor in this accident, the Safety Board

concludes that the FAA should have, but did not, consider the issue of

precipitous terrain when developing and modifying the approach to runway

15.
71

The Safety Board believes that the FAA should incorporate

precipitous terrain adjustments in the runway 15 approach. In addition, the

Safety Board believes the FAA should include a more comprehensive set of

guidelines concerning precipitous terrain adjustments in the TERPS (FAA

Order 8260.3B) Handbook, clarifying the definition of precipitous terrain, and

establishing defined criteria for addressing the potential effects of such

terrain.

FAA flight inspections of instrument approaches are not

normally flown during adverse wind and turbulence conditions, such as those

on the night of the accident, because the flight inspection pilots must fly under

visual flight rules (VFR) to observe man-made obstacles and high terrain.

Therefore, the flight inspectors may not be fully aware of how such adverse

conditions affect the safety of a particular instrument approach. Because the

Safety Board is concerned that non-precision approaches at airports other than

BDL may be adversely affected by wind and turbulence associated with

precipitous terrain, the Safety Board believes that the FAA should review and

evaluate the appropriateness of the let-down altitudes for all non-precision

approaches that have significant terrain features along the approach course

between the initial approach fix and the runway. Airline safety departments

and pilot labor organizations, such as the Allied Pilots Association and the Air

Line Pilots Association, should be consulted as part of this review. In

addition, the Safety Board believes that the FAA should solicit and record

user comments about difficulties encountered in flying a particular approach

to evaluate approach design more accurately.

2.6.2 Approach Plate Terrain Depictions

The single 819-foot obstacle depicted on the final approach

course of most BDL runway 15 VOR approach plates could lead flightcrews

to believe that there was one discrete obstacle, and that it was the only

dangerous point on the final approach (see Figure 1). However, the Safety

Board concludes that the entire ridge line is an obstacle, and that it and similar

terrain close to other airports should be fully depicted on the appropriate

approach charts. As an example, see Figure 4, the BDL approach plate used

by British Airways. The Safety Board continues to believe, as reflected in

Safety Recommendation A-96-102, following the accident near Buga,

Colombia, that the FAA should require that all approach and navigation charts

graphically present terrain information.

73

2.7 Air Traffic Control Factors

2.7.1 ATC Altimeter Setting Distribution Procedures

The approach controller is required to issue the QNH (above sea

level) altimeter setting on initial contact with an arriving flight, in accordance

with the Air Traffic Control Handbook, FAA Order 7110.65. AAL flight

1572 first contacted the approach controller at 0043:41. The controller should

have issued the current altimeter setting of 29.38 inches Hg. at that time. The

controller said that the omission was inadvertent. If the controller had issued

the current altimeter setting on initial contact, the aircraft would most likely

have been 40 feet higher than it actually was when it struck the trees.33 The

survey of tree heights that was performed shortly after the accident indicated

that the trees in the area of initial impact were approximately 60 feet tall.

Therefore, an additional 40 feet might have given the aircraft enough

clearance to miss the trees on the downslope of the ridge. Accordingly, the

Safety Board concludes that this omission by the controller was a contributing

factor in this accident.

There is no requirement for an approach controller to issue an

altimeter change to an aircraft after the initial contact. However, considering

the fact that the pressure changes were described by the weather observer as

"pressure falling rapidly," and especially in light of the controller’s failure to

issue the current altimeter setting (29.38 inches Hg.) upon initial radio contact

and his 0044:34 entry of 29.34 inches Hg. in the ARTS system while the

accident aircraft was on his frequency,34 the Safety Board concludes that it

would have been prudent for the approach controller to have issued the

altimeter setting changes as the airplane neared the airport. The latest

altimeter setting available to the approach controller while the accident flight

was on his frequency was 29.36 inches of Hg. If the flightcrew had received

and correctly entered this setting, it would have resulted in the aircraft being

 33The altimeter setting of 29.42 inches Hg. (the QNH equivalent of the 29.23

inches Hg. QFE setting the flightcrew was using on final approach) minus 29.38 inches Hg.

equals .04, or 40 feet of indicated altitude.

34When he entered 29.34 inches Hg., the controller should have recognized

that this was a substantially lower barometer reading than existed when the accident

airplane initially reported on the frequency (29.38), and it should have reminded him that he

had not provided the flightcrew with a current altimeter setting.
74

approximately 60 feet higher, thus likely enabling it to clear the trees on the

ridge line.

This accident illustrates the safety hazards that may result when

flightcrews of landing aircraft are not informed of current altimeter settings in

circumstances of rapidly falling atmospheric pressure. Therefore, the Safety

Board believes that for arriving aircraft executing instrument approaches at all

airports, during periods in which the weather observer has included in the

weather report the remark, "pressure falling rapidly," controllers should be

required to issue, as frequently as practical, altimeter setting changes to

flightcrews in addition to the altimeter setting issued on initial contact.

2.7.2. Tower Closure and Assistance Provided by the TRACON

Supervisor

The winds on the evening of the accident were strong enough to

bow tower windows and allow water to enter the tower cab, posing an

electrical hazard to the tower controller. The Safety Board therefore

concludes that the closure of the tower was a good managerial decision

because the safety of people in the tower was compromised by the adverse

wind and rain. The TRACON supervisor's presence in the tower to monitor

repairs, and his provision of wind and runway information to the aircraft was

beneficial to the flight. He informed the flight that the runway was clear,

provided landing winds, and he also provided a windshear alert. This

information would not otherwise have been provided to the flightcrew.

Although additional information regarding the current altimeter

setting would have been even more helpful to the flightcrew, the TRACON

supervisor was not required to provide that, or any, information. He was

voluntarily assisting the flight by providing advisory information, and he was

not officially serving as an air traffic controller. Further, the flightcrew had

been told by the approach controller that the tower was not “officially” open,

and therefore, the flightcrew could reasonably assume that there was no

“official” ATC service in the tower. The Safety Board notes that the

supervisor was very careful in his wording and did not give flight 1572

clearance to land. His exact words were, “Bradley tower, uh, landing is at

your discretion, sir....runway does appear clear, you can land and taxi to the

gate at your discretion.”
75

The first officer on two occasions (0054:04 and 0055:06) used

the words “cleared to land,” in conversation with the captain. However,

because the tower was closed, the captain of flight 1572 could land the

airplane only on his own authority. The Safety Board concludes that the

TRACON supervisor’s communications with the flight were appropriate and

aided the flightcrew. He acted in a professional manner, and should be

commended for his willingness to assist the flight under the circumstances.

As further discussed in Section 2.7.4, the ATIS report broadcast

at the time of the accident was based on weather observations almost 2 hours

old, information that would be of little use to flightcrews in the area.

Therefore, the Safety Board concludes that as part of the tower closure

procedure, the ATIS broadcast should have been updated to reflect the

temporary tower closure, and it should have advised flightcrews to obtain

local weather and airport information from another source.

2.7.3 MSAW (Minimum Safe Altitude Warning)

MSAW is a computer program to warn a controller when an

airplane descends or will descend below a predetermined altitude. If the radar

does not receive a signal from a target, the program cannot function. The

MSAW at BDL was set to alarm if the aircraft transmitted two mode C returns

at or below 1,050 feet msl (30 feet below the MDA for the runway 15 VOR

approach). There was no alarm as flight 1572 descended below the MDA

because the aircraft was not in radar contact at that point because of shielding

by the ridge line. There was a radar return recorded at 1,300 feet (above the

MSAW envelope) but because of shielding from the ridge, the aircraft was out

of radar contact for three radar sweeps and was therefore not visible to the

controllers. Then, a single radar return was recorded at 900 feet, followed by

another radar sweep with no recording of the flight, and then two radar returns

were recorded at 800 feet. The MSAW then sounded an alarm, as it should

have under those conditions.35 However, this alarm sounded about 4 seconds

after the airplane had struck the trees.

 35Two consecutive sweeps with radar contact with an airplane are required to

set off the MSAW alarm. This is the reason that the MSAW did not alarm following the

single radar contact at 900 feet.
76

According to the FAA, because of the lack of radar coverage

close to the ridge, the minimums for the VOR 15 approach would have to be

raised to give MSAW protection for this approach. It is not desirable for an

MSAW alarm to occur above the MDA. This would result in an MSAW

false alarm sounding on every approach, making the occasional valid alarm

likely to be ineffective. Because the last radar return before the airplane

struck the trees was recorded at 1,300 feet, the lowest altitude at which the

MSAW could be programmed to activate and be effective is 1,300 feet.

Therefore, to have full MSAW coverage, the approach minimums for this

approach would have to be raised from 1,080 feet msl to somewhat above

1,300 feet msl, to keep the MDA above the alarm point for the MSAW.

However, an MDA this high would defeat the purpose of the instrument

approach. The descent from a 1,350-foot MDA to the runway would have

to start far back along the final approach course, and the ceiling and

visibility minimums would be unrealistically high. The Safety Board

therefore concludes that despite the lack of full MSAW coverage along the

approach, the MSAW operated properly, and that because of topographical

limitations of the BDL local area, it is not practical to provide full MSAW

coverage.

2.7.4 The Outdated ATIS Broadcast

The ATIS report information Victor, based on 2251 EST

weather (from a weather observation taken almost 2 hours before the

accident) was broadcast continually through the time of the accident.

Because of the age of the observation, ATIS Victor was of little use to

flights in the area of BDL. The relieving tower controller, who “entered the

tower a couple of minutes before midnight” said that he listened to the ATIS

but did not notice the time on it, nor did he notice if the SAIDS incoming

information warning light was blinking. This would have indicated that

new weather information was available. He said that the environment was

very noisy (because of wind noise) and that he did not hear SAIDS

incoming information warning tones. The weather sequence, taken at 2252,

was time stamped at 2249:21. However, the clock making the time stamp

was about 4.5 minutes slow. Therefore, the Safety Board believes that it

was actually received at around 2253. The 2351 weather sequence would

have actually been received at around 2358. The Safety Board believes that

the weather information would have been on the display prior to the closing

of the tower. However, the time stamps and readout of the SAIDS indicated
77

that the information was sent at 2358 and would probably have been

displayed when he began his shift. The information would also have been on

the display at the time the tower closed.

If the ATIS had been updated, the altimeter setting would have

been 29.42 inches Hg., (based on the 2352 local observation) a less current

altimeter setting than the one that the flightcrew received from Boston

ARTCC (29.40 inches Hg., based on the 2333 observation). The flightcrew

had actually received an earlier ACARS setting of 29.42 inches Hg.

(erroneously entered in the standby altimeter as 29.47 inches Hg.), the same

setting that would have been provided on the unbroadcast ATIS.36 The Safety

Board concludes that the tower controller being relieved should have advised

the relieving controller that the ATIS needed to be updated, even if it meant

that they had to use the airport police to tell the weather observer to call the

tower with more current weather. Although the failure to update the ATIS

was not a factor in this accident, this failure raises concerns because of the

potential hazards of not having current weather information available for

flights inbound to BDL. Therefore, the Safety Board believes that the FAA

should revise Facility Operation and Administration handbook 7210.3, or

other appropriate orders, to require that when a tower shuts down for any

reason, and if the tower controllers have time to record a new ATIS indicating

that the tower is closed, they should do so.

2.8 Weather Conditions at the Time of the Accident

Possible downdrafts of about 400 feet per minute may have

existed near the lee (northwest) side of the ridge where the tree strike

occurred, according to the NCAR simulation. Douglas estimated a

maximum updraft of about 600 feet per minute in this same geographical

area. However, updrafts are not common on the lee side of ridge lines

(downdrafts usually occur on the lee side of an obstacle). On the other

hand, the NCAR simulation is dependent on an initial steady wind direction of

160 degrees, which probably does not accurately represent the accident

conditions, as the winds were variable, not steady. Variation of the wind

direction would result in a change in the location of updrafts and downdrafts

in relation to the ridge. In addition, the presence of a horizontal axis vortex

 36The unbroadcast ATIS wind direction, velocity and gust factor would have

been similar to that of the earlier ATIS broadcast.
78

on the lee side of the ridge could have produced a localized updraft along the

flightpath of the airplane. The Safety Board concludes that, although the

variable wind conditions at the time of the accident may have caused localized

updrafts and downdrafts in the area, the DFDR data indicates that there were

no large-scale updrafts or downdrafts that would have affected the accident

aircraft.

During the approach to runway 15, to the point at which flight

1572 struck the trees, the airplane would have encountered moderate

turbulence and localized updrafts and downdrafts due to the interaction

between strong low altitude winds and rough terrain along the flightpath.

Windshear due to strong gusty low altitude winds also occurred following the

tree strike, as the airplane was on approach to the runway. An estimated mean

wind profile indicated a decreasing headwind as the airplane descended to the

runway.

Although windshear was occurring as the airplane approached

and passed over the ridge line, it was the gustiness of the low altitude winds,

rather than a small-scale weather feature, that significantly affected airplane

performance. Airspeed excursions amounted to only about 10 knots. Further,

a descent rate of about 1,100 feet per minute was initiated by the flightcrew

from about 1,840 feet msl and was maintained until tree contact. The linear

nature of the pressure altitude trace indicates that the airplane’s flightpath was

probably not significantly affected by updrafts, downdrafts, or windshear.

Such an effect would be seen as a deviation from the near linear pressure

altitude trace. Therefore, the Safety Board concludes that the decreasing

headwind shear seen in the estimated mean wind profile data was not severe

enough to cause the flightcrew to deviate below the MDA.

Along the approach to runway 15, cloud bases were near 2,000

feet with multiple cloud layers above, and the tops of the clouds were above

15,000 feet. Flight visibility was near 0 miles in the clouds and 2 to 3 statute

miles below the lowest cloud base. The first officer reported "there's the

runway straight ahead " at 0055:57. The airplane was about 2.1 miles from

the end of the runway at this time. Moderate rain probably occurred along the

approach to the runway with more intense rain near the runway.

Given the above described conditions, the Safety Board

concludes that the weather at the time of the accident was not severe enough
79

to cause the aircraft to deviate below the MDA, and did not contribute to the

accident.

2.8.1 LLWAS Equipment

The northwest LLWAS sensor was physically out of alignment

by 38 degrees and was corrected subsequent to the accident. Analysis of the

LLWAS data, according to the FAA, indicated that this sensor did not

appear to degrade the entire LLWAS system to any significant degree during

the analyzed period.

The Safety Board could not determine whether the LLWAS

system would have provided another windshear alert if the sensor had not

been misaligned. Nevertheless, the Safety Board considered the possibility

that if the northwest sensor had been correctly aligned, it might have alerted

due to erratic wind conditions; and an LLWAS alert from this sensor in the

area of flight 1572 might have prompted the flightcrew to perform a missed

approach. The Safety Board could not rule out this possibility. However, the

Safety Board believes that it is more likely that if the flightcrew had received

a northwest LLWAS alert from the tower controller, they would have

continued the approach because under the known turbulence and erratic wind

conditions, LLWAS alerts are to be expected. Thus, under these conditions, it

would not be unreasonable for a flightcrew to react to such a warning by more

closely monitoring their airspeed, rather than immediately initiating a missed

approach. Therefore, the Safety Board concludes that the misaligned LLWAS

sensor did not contribute to this accident.

According to the FAA, procedures are in place to check and

correct the alignment of sensors based on the SPES analysis, which is run on a

regular basis. However, the FAA also indicated that because of manpower

shortages, it can take 3 to 6 months after discrepancies are noted for the

alignment of the sensors to be examined and adjusted by airport personnel.

The Safety Board concludes that 3 to 6 months after discrepancies are noted is

an unacceptable period of time to verify the accuracy of sensor alignment,

since wind direction can have a direct bearing on the windshear detection

capability of the system. Therefore, the Safety Board believes that the FAA

should develop a plan to physically check and correct wind sensor alignment

in a more timely manner.
80

The Safety Board is also concerned that the FAA’s process of

“recertifying” the LLWAS--despite the implication that “recertification”

signifies that the system has been found to comply with all original

certification requirements--does not include checking that the sensors are

properly aligned. Although the FAA indicated that the misalignment did not

appear to degrade the system during the analyzed period (October 31, 1995 to

November 12, 1995), this result is relevant only to the wind conditions

experienced during that period. A misalignment of 38 degrees could clearly

compromise the effectiveness of the system under some wind conditions.

Accordingly, the Safety Board believes that the FAA should evaluate its

LLWAS recertification process, and ensure that the process addresses the total

functional capability of the system.

2.9 Survival Factors

2.9.1 The Malfunctioning Escape Slide

Instructions for rigging the inflation cable, contained in the

Douglas DC-9/MD-80 Maintenance Manual 25-62-00-2-2, page 204,

paragraph 11, were ambiguous. At the time of the accident, they stated:

“Check that loop on firing lanyard is secured to girt tab with retaining ring on

manual inflation handle; then, secure lanyard cover flap over firing lanyard.”

The instructions did not specifically call for the inflation cable to pass through

a grommet on a tab near the girt bar before the cable is connected to the

retaining ring on the manual inflation handle. In addition, the diagram in the

rigging instructions did not display the grommet or the tab, or the inflation

cable passing through the grommet on the tab near the girt bar before the

cable is connected to the manual inflation handle (see Figure 5). This is

required for the slide to inflate properly. The Safety Board concludes that

because of the ambiguous instructions that appeared in the Douglas

Maintenance Manual, operators of MD-80 and DC-9 series airplanes could be

misrigging emergency evacuation slides. Therefore, the Safety Board

believes that the FAA should require all operators to inspect immediately all

MD-80 and DC-9 floor level exits to ensure that evacuation slides have been

properly rigged.

As a result of this accident, American Airlines took immediate

action to clarify instructions in its maintenance manual and is conducting a

fleet-wide inspection of all emergency evacuation slides on its MD-80
81

airplanes. Douglas also took action and revised its maintenance manual

instructions for installation of evacuation slides to include improved diagrams

showing proper routing of the inflation cable through the grommet tab, and to

include instructions to “[p]ass [the] inflation cable loop through [the]grommet

tab.” (See Figure 6.) (The “inflation cable” had previously been referred to in

the manual as the “firing lanyard.”) Although these revisions clearly and

accurately depict the proper routing of the inflation cable, the Safety Board is

concerned that the change in terminology from “firing lanyard” to “inflation

cable” was not reflected in all the maintenance manual diagrams and

instructions dealing with the installation and removal of evacuation slides. In

several places, the cable is still referred to as a “firing lanyard.” The Safety

Board concludes that because Douglas uses two different terms (“firing

lanyard” and “inflation cable”) for the same part in its MD-80 and DC-9

maintenance manuals, the manual remains potentially confusing. Therefore,

the Safety Board believes that the FAA should require Douglas Aircraft

Company to review and amend its MD-80 and DC-9 maintenance manuals so

that terminology used in graphics and instructions pertaining to the

installation and removal of evacuation slides are clear and consistent.

2.9.2 Evacuation Route Difficulties

The aisle and areas in front of the escape doors that constituted

the escape routes were partially blocked by passenger shoes during the

evacuation. This could have caused injuries or loss of life in the case of an

interior fire or other critical situation. The practice of commanding all

passengers to remove shoes during evacuations was originally targeted

primarily at high heeled shoes, and was intended to prevent slide punctures.

But modern slide design and strengthened fabric material now used in slide

manufacturing make the policy outdated. In addition, (with the exception of

high heeled shoes) safety is served by passengers wearing shoes because they

can exit an airplane and move away from an evacuated airplane more readily.

It may still be appropriate for crewmembers to instruct female

passengers to remove high-heeled shoes that could cause injuries during an

evacuation. Experience has shown that ankle and leg injuries are more likely

to result from passengers wearing high heels. In addition, other injuries could

also occur to rescue personnel and passengers, as the passenger wearing high

heels slides down to waiting individuals at the bottom of the slide.
82

GIRT BAR HOO

IRING

ANYARD

YARD COVER

P (CLOSED)

HANDLE (ARMED POSITION)

KS

Figure 5.--Instruction diagram for rigging the firing lanyard (inflation cable).
83

f

MANUAL INFLATION

INFLATION CABLE , HANDLE \/

pVELC

.

\

&

KEY RING

GRo-TT.~G’”=

GIRT ~ UNARMED

RO

Figure 6.--Revised instruction diagram for rigging the inflation cable,
84

However, the Safety Board concludes that directing all

passengers to remove shoes during evacuations may not be in the best

interests of safety. There is no FAA policy regarding issuing commands for

shoe removal during an evacuation. Although American Airlines is the only

major carrier the Safety Board is aware of that instructs passengers to remove

shoes during an evacuation, the Safety Board is concerned that there is no

uniform policy or standard to which all operators (large and small) must

adhere. The Safety Board therefore believes that the FAA should develop a

uniform policy on shoe removal during evacuations, and require that all

operators train their flight attendants to issue commands during an emergency

evacuation consistent with that policy.
85

3. CONCLUSIONS

3.1 Findings

1. The flightcrew had the proper FAA airmen certifications

and were qualified in accordance with applicable

regulations and company requirements. They received

the proper amount of crew rest before the accident flight

and did not appear to be under unusual psychological

pressure.

2. The airplane was properly fueled; passengers and cargo

were loaded in accordance with AAL weight and balance

requirements.

3. The flight was released in accordance with AAL dispatch

procedures.

4. The weather at BDL was at or above the required

minimums for landing, and included overcast clouds,

visibility restricted by moderate rain, and strong, gusty

wind conditions.

5. There was no evidence of a malfunction of the pitotstatic system, the autopilot system, the ground proximity

warning system, the windshear warning system, or any

flight control system that could have contributed to this

accident.

6. With regard to the operation of flight 1572, AAL

weather forecasts, as documented in the SIGMEC, were

substantially correct.

7. AAL’s FAA-approved system of providing flightcrews

with more focused forecasts, in the form of SIGMECs, is

a valid method of weather dissemination.

8. The pressure decrease of about 1 millibar shown by the

National Center for Atmospheric Research simulation for
86

the time and place of the accident was not

underestimated by a factor of 2 to 3 because the flight

data recorder’s altitude trace did not contain an altitude

spike that would have resulted from a significant

atmospheric pressure change.

9. With the exception of a current altimeter setting, the

flightcrew had adequate information concerning the

weather at BDL as they began their descent to the

airport.

10. Because the flightcrew knew that the atmospheric

pressure was falling rapidly, they should have requested

a current altimeter setting from the BDL approach

controller when one was not given, as required, upon

initial radio contact.

11. If the flightcrew had received a current altimeter setting

from the BDL approach controller when the flight first

contacted the approach controller at 0043, it most likely

would have resulted in the aircraft being 40 feet higher

than it was when it struck the trees, and it might have

given the aircraft enough clearance to miss the trees.

12. At the time of the accident, the indicated altitude (height

above airport elevation) that the airplane’s QFE altimeter

was indicating was about 76 feet too high (based on the

altimeter setting received at 0030), resulting in the

airplane being 76 feet lower than indicated on the

primary altimeters.

13. Although the flightcrew did not use the most current

QNH setting they had available (29.40 inches of Hg.) in

the standby altimeter, this error did not affect the

accident sequence of events because the flightcrew had

the correct, but outdated, QFE setting (29.23 inches Hg.)

in the altimeters they were using when the accident

occurred.
87

14. If the first officer had monitored the approach on

instruments until reaching minimum descent altitude

(MDA) and delayed his search for the airport until after

reaching the MDA, he would have been better able to

notice and immediately call the captain’s attention to the

altitude deviation below the MDA.

15. The excellent crew resource management and flight

skills that the flightcrew used, as reflected on the CVR

recording following their encounter with the trees, were

directly responsible for limiting the number of injured

passengers to one individual.

16. FAA quality control was inadequate for accurately

resolving the height of the trees on the ridge line.

17. There is great value in flying non-precision approaches

with a constant rate or angle of descent until the airport

environment can be visually acquired, if the avionics

aboard the airplane can safely support such a procedure.

18. The FAA should have, but did not, consider the issue of

precipitous terrain when developing and modifying the

approach to runway 15.

19. The entire ridge line on the final approach course to

runway 15 at BDL is an obstacle and it, and similar

terrain close to other airports, should be fully depicted

upon the appropriate approach charts.

20. Considering the fact that the pressure changes were

described by the weather observer as "pressure falling

rapidly," and especially in light of the controller’s failure

to issue the current altimeter setting (29.38 inches Hg.)

upon initial radio contact, and his 0044:34 entry of

29.34 inches Hg. in the ARTS system while the accident

aircraft was on his frequency, it would have been

prudent for the approach controller to have issued the
88

altimeter setting changes as the airplane neared the

airport.

21. Closure of the tower was a good managerial decision

because the safety of people in the tower was

compromised by the adverse wind and rain.

22. The TRACON supervisor’s communications with the

flight were appropriate and aided the flightcrew. He

acted in a professional manner and should be

commended for his willingness to assist the flight under

the circumstances.

23. As part of the tower closure procedure, the ATIS

broadcast should have been updated to reflect the

temporarily closed tower, and it should have advised

flightcrews to obtain local weather and airport

information from another source.

24. Despite the lack of full minimum safe altitude warning

(MSAW) coverage along the approach, the MSAW

operated properly, and because of topographical

limitations of the BDL local area, it is not practical to

provide full MSAW coverage.

25. The tower controller being relieved should have advised

the relieving controller that the ATIS needed to be

updated, even if it meant that they had to use the airport

police to tell the contract weather observer to call the

tower with more current weather information.

26. Although the variable wind conditions at the time of the

accident may have caused localized updrafts and

downdrafts in the area, the DFDR data indicates that

there were no large-scale updrafts or downdrafts that

would have affected the accident aircraft.

27. The decreasing headwind shear seen in the estimated

mean wind profile data was not significant.
89

28. The weather at the time of the accident was not severe

enough to cause the aircraft to deviate below the MDA.

29. Three to 6 months after discrepancies are noted is an

unacceptable period of time to verify the accuracy of low

level windshear alert system (LLWAS) sensor alignment,

since wind direction can have a direct bearing on the

windshear detection capability of the system.

30. The misaligned LLWAS wind sensor did not contribute

to this accident.

31. Because of the ambiguous instructions that appeared in

the Douglas Maintenance Manual, operators of MD-80

and DC-9 series airplanes could be misrigging

emergency evacuation slides.

32. Because Douglas uses two different terms (“firing

lanyard” and “inflation cable”) for the same part in its

MD-80 and DC-9 maintenance manuals, the manual

remains potentially confusing.

33. Directing all passengers to remove shoes during

evacuations may not be in the best interests of safety.
90

3.2 Probable Cause

The National Transportation Safety Board determines that the

probable cause of this accident was the flightcrew’s failure to maintain the

required minimum descent altitude until the required visual references

identifiable with the runway were in sight. Contributing factors were the

failure of the BDL approach controller to furnish the flightcrew with a current

altimeter setting, and the flightcrew’s failure to ask for a more current setting.
91

4. RECOMMENDATIONS

As a result of the investigation of this accident, the National

Transportation Safety Board makes the following recommendations:

--to the Federal Aviation Administration:

Evaluate Terminal Instrument Procedures (TERPS) design

criteria for non-precision approaches to consider the

incorporation of a constant rate or constant angle of descent to

minimum descent altitude in lieu of step-down criteria. (A96-128)

Examine and make more effective the coordinating efforts of

the flight inspection program and the procedures development

program, with emphasis on ensuring quality control during the

development, amendment, and flight inspection process for

instrument approaches. (A-96-129)

Incorporate precipitous terrain adjustments in the BDL

runway 15 approach. (A-96-130)

Include a more comprehensive set of guidelines concerning

precipitous terrain adjustments in the Terminal Instrument

Procedures (TERPS) (FAA Order 8260.3B) Handbook,

clarifying the definition of precipitous terrain, and

establishing defined criteria for addressing the potential

effects of such terrain. (A-96-131)

Review and evaluate the appropriateness of the let-down

altitudes for all non-precision approaches that have significant

terrain features along the approach course between the initial

approach fix and the runway. Airline safety departments and

pilot labor organizations, such as the Allied Pilots Association

and the Air Line Pilots Association, should be consulted as

part of this review. (A-96-132)
92

Solicit and record user comments about difficulties

encountered in flying a particular approach to evaluate

approach design more accurately. (A-96-133)

For arriving aircraft executing non-precision instrument

approaches at all airports, during periods in which the official

weather report includes the remarks, “pressure falling

rapidly,” controllers should be required to issue as frequently

as practical altimeter setting changes to flightcrews in

addition to the altimeter setting issued on initial contact. (A96-134)

Revise Facility Operation and Administration handbook

7210.3, or other appropriate orders, to require that when a

tower shuts down for any reason, and if the tower controllers

have time to record a new automatic terminal information

service (ATIS) indicating that the tower is closed, they should

do so. (A-96-135)

Develop a plan to physically check and correct low level

windshear alert system (LLWAS) wind sensor alignment in a

timely manner. (A-96-136)

Evaluate the low level windshear alert system (LLWAS)

recertification process, and ensure that the process addresses

the total functional capability of the system. (A-96-137)

Require all operators to inspect immediately all MD-80 and

DC-9 floor level exits to ensure that evacuation slides have

been properly rigged. (A-96-138)

Require Douglas Aircraft Company to review and amend its

MD-80 and DC-9 maintenance manuals so that terminology

used in graphics and instructions pertaining to the installation

and removal of evacuation slides are clear and consistent. (A96-139)
93

Develop a uniform policy on shoe removal during

evacuations, and require that all operators train their flight

attendants to issue commands during an emergency

evacuation consistent with that policy. (A-96-140)

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

James E. Hall

Chairman

Robert T. Francis II

Vice Chairman

John Hammerschmidt

Member

John J. Goglia

Member

George W. Black

Member

November 13, 1996

95

APPENDIXES

APPENDIX A

INVESTIGATION AND HEARING

1. Investigation

The National Transportation Safety Board was notified of the

accident about 0600 on November 12, 1995. An investigative team was

dispatched that morning and arrived at Bradley International Airport shortly

thereafter. Investigative specialists for meteorology, air traffic control,

operations, airplane performance, structures, systems, and powerplants

gathered evidence on scene for about 1 week. Investigative groups for the

cockpit voice recorder and the flight data recorder were also formed in

Washington, D.C.

Parties to the investigation included the Federal Aviation

Administration, Bradley International Airport, American Airlines, the Allied

Pilots Association, United Technologies Pratt and Whitney, the National Air

Traffic Controllers Association, Douglas Aircraft Company, and Jeppesen

Sanderson, Inc.

2. Public Hearing

There was no public hearing conducted in conjunction with this

investigation.
96

APPENDIX B

COCKPIT VOICE RECORDER TRANSCRIPT

LEGEND

RDO Radio transmission from accident aircraft

CAM Cockpit area microphone voice or sound source

INT Transmissions over aircraft interphone system

CTR-1 Radio transmission from the first Boston center controller

CTR-2 Radio transmission from the second Boston center controller

FED5 Radio transmission from Federal Express flight #Five

UNK Radio transmission received from unidentified aircraft

ATIS Radio transmission received from Bradley ATIS

APR Radio transmission from Bradley approach control

TWR Radio transmission from Bradley control tower

PA Transmission made over aircraft public address system

-1 Voice identified as Pilot-in-Command (PIC)

-2 Voice identified as Co-Pilot

-3 Voice identified as female flight attendant

-4 Aircraft mechanical voice

-? Voice unidentified

* Unintelligible word

@ Non pertinent word

# Expletive

% Break in continuity

( ) Questionable insertion

[ ] Editorial insertion

.... Pause

Note 1: Times are expressed in eastern standard time (EST).

Note 2: Non pertinent conversation where noted refers to conversation that does not directly concern the operation, control, or

condition of the aircraft, the effect of which will be considered along with other facts during the analysis of flight crew

performance.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENTSTART of RECORDINGSTART of TRANSCRIPT0025:39CAM [6:05 minutes of non-pertinent conversation between captain

and first officer]

0031:51CAM [sound of several clicks similar to cockpit door release being o

activated]

0031:54CAM-1 hey Z.0032:01CAM [sound similar to cockit door being operated]0032:06CAM-2 good luck on your landing there captain.0032:07CAM-1 [sound of laughter]0032:10CAM [sound similar to cabin to cockpit chime]0032:14INT-1 hello.0032:15INT-3 were you looking for me?0032:16INT-1 yeah Z, we just got a message it's really, it's going to be real

bumpy on the way down uh, to landing.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0032:22INT-3 OK.0032:23INT-1 so, put everything away or whatever as soon as we start down

uh, mater of fact we're starting our descent now so you canlock it all up and prepare for landing.

0032:25CTR-1 American fifteen seventy two des

maintain flight level one niner zer

0032:31RDO-2 pilot's discretion to one nine oh, A

two.

0032:32INT-3 OK, thank you.0032:35CAM-2 pd to one nine oh, boss.0032:37CAM-1 yeah, lets go down.

0032:39RDO-2 out of three five oh for flight level 

fifteen seventy two.

0032:42CAM-1 you might want to cool it down too. it's gonna get bumpy or

they'll be throwing up *.

0032:46CTR-1 American fifteen seventy two rog

on one three four point three.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT

0032:52RDO-2 thirty four three, we'll see you Am

two.

0032:55CTR-2 ... four three.0032:56UNK two niner four three, roger.0032:59CTR-2 FedEx five, how is your ride sir?0033:04FED5 we were getting some uh, light to 

I'll say that turbulence is uh, light 

0033:12ATIS [heard through captain's audio pa

aircraft the wings to the left of *** met x-ray three is valid for severe zero thousand. pre departure cleadvise on initial contact you have information Victor, zero three five six two, dew point five seven, wineight, gust three niner. altimeter proach in use, ILS runway two fofive. notice to airman, runway tw

0033:15CTR-2 FedEx five roger, sounds like it's 

0033:19CAM-2 ##.

0033:21FED5 hasn't been too bad so far.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT

0033:23RDO-2 Boston, American fifteen seventy 

for one nine oh.

0033:27CTR-2 American fifteen seventy two Bos

scend and maintain one one thoutimeter two niner four zero.

0033:35RDO-2 twenty nine forty, out of three fou

sand American fifteen seventy tw

0033:44CAM-2 boss, I'm goin to get the ATIS real quick before, turbulence occurs. ** you know what I mean, I'm off. you got it?0033:52CAM-1 I'm sorry, what?0033:53CAM-2 I'm gonna get the ATIS real quick.0033:56CAM-1 obviously I'm gonna want one five for ***.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT

0034:00ATIS [heard through the first officer's a

port informatin Victor, zero three two thousand two hundred scattetwo thousand seven hundred ovemiles, light rain. temperature six seven. wind one six zero two eigtimeter two niner five zero. approtwo four or VOR runway one fiveway two four and one five open ashear advisories are in effect. taaircraft with a wing span less thaenty one feet. SIGMET x-ray threbulence below one zero thousandances are available. advise on inVictor.

0034:47CAM-2 I'm back. both runways are wet. ILS two four, VOR one five.0034:52CAM-1 alright. ** this is like three fifty one so it's like an hour and a

half old.

0034:56CAM-2 low level wind shear advisories, severe turbulenceand all of that.0035:03CAM-1 OK I'm off.0035:04CAM [sound of click similar to PA button being pressed]0035:05CAM-2 I'm back.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0035:06PA-1 ah, we started our descent. now we're about a hundred miles

away from uh Bradley's Field right now. be touching down inabout twenty five minutes or so. ....and latest temperature'ssixty two degrees and just calling it uh, light rain however thewinds uh, pretty uh, pretty high. they're saying the winds are upto thirty miles an hour or so. so it might get a little choppy. rightnow they're reported some uh, moderate turbulence on the descent. might just get a little choppy on the way down.

0035:46CAM-1 Ok, uh,0036:00CAM-1 just watch me the whole way, alright?0036:03CAM-2 yea man, you got it.0036:04CAM-1 any comments scream out. **.0036:11CAM-2 ** you're gonna get a lot of turbulence ***.0036:16CAM-1 *.0036:16CAM-2 ** you know how to land it.0036:17CAM-? *.0036:20CAM-1 let's go to pumps on high.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0036:23CAM-? ****.0036:36CAM-2 I'll tell you, when I was an engineer, new with the airlines I

watched a guy he's uh, nobody likes him he's a seven twocaptain, I forgot his # name. all the Navy guys, man they hatehis guts. he's still on the seven two. he thinks he's an IP at theRAG.

0036:51CAM-1 uh.0036:54CAM-2 I watched him land in thirty knots of direct cross, up at Bradley,

when I was a wrench, and it scared the # out of me. Actually itscared me bad. some of the flying we do here is much harderthan...

0037:05CAM-1 yeah, yeah, I agree, I agree.0037:13CAM-2 just fight'n it all the way down.CAM [thirty four seconds of nonpertinent conversation between

captain & first officer.]

0038:03CAM-1 OK, one five. what gate are we going to?0038:08CAM-2 gate eight.0038:42CAM-1 gettin' a lotta rain out there.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0038:45CAM-2 altimeters?0038:51CAM-1 I'll tell you, flying at night I don't like it worth a #. twenty nine

fifty?

0038:56CAM-2 yea, we they called twenty nine forty seven when we started

down *** what ever you want.

0039:03CAM-1 OK.0039:07CAM-2 pumps are up. you want these lights?0039:09CAM-1 * I think you can leave them off for now.0039:16PA-1 flight attendants prepare for landing please.0039:18CAM-2 reset and cross-checked. ***.0039:27CAM-1 OK, reset and cross-checked ***.0039:31CAM [several unintelligible comments between captain and first officer]0039:56CAM-1 we'll be, we'll be out of icing now. *****.0040:01CAM [sound similar to stabilizer-in-motion horn]
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0040:13CAM [sound of yawn]0040:33CAM-1 what's the overcast?0040:35CAM-2 twenty seven hundred.0040:44CAM-2 *** shootin' the # VOR man.0040:49CAM-1 I've got uh, thirteen dash one plate. ** make that three February, ninety five.0041:02CAM-2 that's right, three February ninety five, that's it.0041:04CAM-1 OK, I'm showing VOR runway one five. frequency one oh nine

zero. our inbound's one forty eight. MISTR at three, thirty fivehundred. cleared down to two thousand at DILLN, five DME.we're cleared down all the way to uh, nine hundred and eightfeet. missed is climb to three thousand out the uh

0041:26CAM-2 straight out Bradley VOR one forty nine ****.0041:38CAM-1 plus eleven.0041:39CAM-2 punch the tail?0041:40CAM-1 tail on.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0042:25CAM-2 happy hour, two for one *.0042:28CAM-B [sound of laughter]0042:31CAM-2 twelve for eleven.0042:32CAM-1 eleven *.0042:37CAM-2 * raining out.0042:37CAM [sound of snap similar to chart holder being released]0042:48CAM-1 one seventy four's the elevation so, twenty nine, twenty three.0042:59CAM-1 reset and cross checked.0042:59CAM-2 minus uh.0043:02CAM-1 showing seventy *.0043:04CAM-2 flight instruments and bugs.0043:05CAM-1 check ** feet difference.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0043:08CAM-? tell me what else you got.0043:11CAM-1 flight instruments and bugs uh, two eighty uh, wings level pretty

good on the horizon, heading checks. peeps are down, finalbug's..

0043:21CAM-2 ** goin' to be one twenty seven for forty flaps.0043:26CAM-1 set and cross checked.0043:28CAM-2 did you already seat the #? # been seated?0043:30CAM-1 yeah I did.0043:32CAM-2 I thought I heard you say # be seated.

0043:32CTR-2 American fifteen seventy two con

one two five point eight. have a g

0043:37RDO-2 twenty five eight, we'll see ya, Am

two.

0043:41RDO-2 Bradley approach, American fifte

thousand, information Victor.

0043:49APR American fifteen seventy two, Bra

expect VOR runway one five app
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0043:55CAM-1 OK.

0043:56RDO-2 Roger.0044:04APR American fifteen seventy two, fly 

zero.

0044:07RDO-2 one zero zero, American fifteen s

0044:13CAM-1 one zero zero, one oh nine, one forty eight.0044:20CAM-1 I'll use uh, medium brakes *.0044:23CAM [sound of two clicks]0044:26CAM-2 can't set it yet.0044:27CAM-1 no, no ***.0044:28CAM-2 I'm so stupid. I is stupid with a capital s. definitely known as

mistah.

0044:38CAM-1 what?0044:41CAM-2 MISTR, MISTR.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0044:43CAM-2 ten miles out.0044:45CAM-1 yeah, then DILLN.0044:47CAM-2 at five.0045:10CAM-1 lotta rain.0045:12CAM-2 I can see that.

0045:54APR American fifteen seventy two, de

thousand.

0045:57RDO-2 eleven for four thousand, Americ

0045:59CAM-1 set.0046:21CAM-1 plus thirteen.0046:22CAM [sound of two thumps similar to switches being moved]

0047:01APR American fifteen seventy two the 

zero at two nine gusts three nine

0047:05RDO-2 copy.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0047:13CAM [sound of laughter]0047:14CAM [sound similar to stabilizer in motion horn]0047:28CAM-1 well you got enough gas to go back.0047:29CAM-2 it's only forty five off the bug.0047:32CAM-1 do you have any other choices?0047:44CAM-2 well you have runway one five.0047:45CAM-1 you bet, that's where we're going.0047:48CAM-2 [sound of laughter]0048:03CAM-1 how about slats extend, please.0048:04CAM [sound of click similar to flap/slat handle being moved]0048:09CAM-? *** #.0048:09CAM [sound of rattling similar to aircraft going through turbulence]
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0048:33CAM-? moderate....0048:36CAM-? yes.

0048:39APR American fifteen seventy two, tur

zero and intercept the final.

0048:43RDO-2 American fifteen seventy two.

0048:49CAM-2 VOR's alive.0048:59CAM-1 **.0049:00CAM-2 you want you want this one?0049:01CAM-2 I got this ready.0049:02CAM-1 let's hold out.0049:06CAM-2 ten miles at thirty five hundred.0049:11CAM-1 yeah, I just got that *0049:18CAM-? OK.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0049:19CAM-2 approaching four thousand.0049:21CAM-1 OK.0049:21CAM-1 VOR capture.0049:25CAM-1 slowing down.0049:31CAM-1 *** five.0049:32CAM-2 **.0049:39CAM-1 * set the radar *.0049:40CAM-2 alright.

0049:41APR American fifteen seventy two, you

MISTR. cross MISTR at or abovhundred, cleared for the VOR run

0049:49RDO-2 OK we'll uh, we're cleared for the 

cross MISTR at or above uh, thirtcan fifteen seventy two.

0049:55CAM-1 set. comin' down.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT

0049:57APR American fifteen seventy two, rog

uh, the tower is closed at this timsure, due to uh, problem with uh so I'll need a uh, a down uh time on this frequency uh, for that.

0049:59CAM [sound similar to stabilizer in motion horn]

0050:16RDO-2 roger and, what happened on the 0050:19APR it's just loose. they've got carpen

boarding it up...

0050:23CAM-2 it blew out.

0050:23APR ... but once that's done the tower 0050:25RDO-2 copy.

0050:28CAM-1 flaps eleven, please.0050:30CAM-2 you got it.0050:34CAM [sound of rattling similar to aircraft going through turbulence]0050:51CAM-2 OK, five hundred feet, looking good, you can go down to, step

down to two thousand by five miles. but then it ...
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0050:58CAM-1 what's your **?0051:03CAM-2 I think it's gonna be smoother once we get out of the weather.0051:05CAM-1 yeah.0051:10CAM-2 OK, you're at thirty five hundred *.0051:16CAM-1 OK, we're cleared down to where?0051:17CAM-2 you're cleared down to two thousand MSL at DILLN. by

DILLN....

0051:21CAM-1 OK, two thousand set and armed.0051:22CAM-2 ...five miles * so it's good. two thousand is set and armed.0051:27CAM-1 flaps fifteen.0051:28CAM-2 down to flaps fifteen.0051:30CAM [sound similar to flap handle being moved and sound of rattling

similar to aircraft going through turbulence]

0051:44CAM-1 OK, comin' down.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0051:44CAM-2 ten miles.0051:48CAM-1 comin' back to idle.0051:49CAM-2 roger.

0051:56APR American fifteen seventy two uh, 

the final? looks like you're uh, a 

0052:01CAM-1 yeah, looks like we're to the left of it.

0052:02RDO-2 copy.

0052:03APR American fifteen seventy two rog

one seven zero at two four, gusts 

0052:07RDO-2 roger.

0052:11CAM-1 how 'bout gear down, please.0052:12CAM [sound similar to landing gear handle being operated followed

sound similar to nose gear door opening]

0052:24CAM-2 * thousand and five.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT

0052:24

APR American fifteen seventy two uh, 

the tower, it's not really officially ochange to tower frequency one tw

0052:34RDO-2 OK, you're not gonna need that d0052:36APR negative.0052:38RDO-2 see ya.0052:39APR good day.

0052:42CAM-1 OK, it's two thousand feet until five miles.0052:43CAM [sound similar to stabilizer in motion horn]0052:45CAM-2 that's it.0052:46CAM-1 coming back. flaps twenty eight.0052:47CAM [sound similar to flap handle being moved]0052:50CAM-2 OK, going down to nine oh eight, huh?0052:53CAM-1 yeah.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0052:54CAM-2 set and armed *.0052:56CAM-1 naw you don't have to do *, three thousand **.0052:58CAM-2 three thousand, missed.0053:04CAM [sound similar to stabilizer in motion horn]0053:11CAM-2 * VOR, right on track.0053:13CAM-1 OK.0053:16CAM-2 gear's down and green spoiler lever?0053:18CAM [sound of click similar to spoiler lever being armed]0053:19CAM-1 armed.0053:20CAM-2 you got brakes are going to medium.0053:23CAM [unidentified high frequency sound of decreasing pitch for approximately one second duration]0053:26CAM-1 **.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0053:27CAM [sound similar to stabilizer in motion horn]

0053:27RDO-2 hey tower, American fifteen seve

mile final for runway one five.

0053:32TWR American fifteen seventy two, 's B

is at your discretion sir. the wind five, peak gust to four zero. and pear clear. you can land and taxcretion.

0053:40CAM [unidentified high frequency sound of decreasing pitch for approximately one second duration]0053:43CAM-2 showing you going through the course.

0053:46RDO-2 are you uh and uh, what are you 

winds?

0053:50TWR one seven zero at two four.0053:53RDO-2 copy.

0053:58CAM [sound of rattling similar to aircraft going through turbulence]0054:01CAM-1 flaps forty.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0054:02CAM [sound of click similar to flap/slat handle being moved]0054:04CAM-2 OK, annunciator lights checked, flaps and slats at forty forty

and land, you're cleared to land dude.

0054:22CAM-1 OK, give me a thousand down.0054:23CAM-2 one thousand down, you got it.0054:34CAM-2 you're showin' **.0054:35CAM-1 **.0054:41CAM-2 you got a long ways to go.0054:47CAM [sound similar to stabilizer in motion horn]

0054:51TWR wind shear alert uh, centerfield o

five. the uh, northeast boundary, four, one niner zero at twelve at t

0055:01RDO-2 copy.

0055:06CAM-2 there's a thousand feet. you got forty forty land, cleared to

land.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0055:09CAM-1 OK.0055:11CAM-2 * now. nine hundred and eight is your uh...0055:14CAM-1 right.0055:16CAM-2 your * bug.0055:18CAM [sound of rattling similar to aircraft going through turbulence]0055:25CAM-2 you're going below your...0055:26CAM-4 sink rate...0055:28CAM-2 **.0055:29CAM-4 ..sink rate...0055:30CAM [sound of impact]0055:30CAM-4 sink rate...0055:30CAM-4 [sound of four beeps followed by]0055:31CAM-4 wind shear, wind shear...
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0055:32CAM-? go.0055:32CAM-4 wind shear...0055:33CAM-2 go, go around.0055:33CAM-1 we're going. going, going around, going around.0055:35CAM [sound of horn]0055:35CAM-4 landing gear...0055:36CAM [sound of horn]0055:37CAM-4 [sound of four beeps followed by]0055:38CAM-4 wind shear, wind shear, wind shear.0055:39CAM-1 flaps fifteen, positive rate, gear up.0055:41CAM [sound of horn]0055:41CAM-4 landing gear.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0055:43CAM-2 you want the gear up?0055:43CAM-1 yep.0055:44CAM [sound of horn]0055:45CAM-4 landing gear.0055:46CAM-? ###.0055:46CAM [sound of horn]0055:47CAM-4 landing gear.0055:48CAM [sound of horn]0055:50CAM-4 landing gear.0055:51CAM [sound of horn]0055:52CAM-4 landing gear.0055:53CAM-1 left motor's failed.0055:56CAM-1 **.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0055:57CAM-2 there's the runway straight ahead.0055:58CAM-1 OK.0056:00CAM-1 tell 'em we're goin' down. tell 'im emergency.

0056:02RDO-2 tower call for emergency equipm

down on the runway.

0056:06CAM-2 you want the gear back down?0056:07CAM-1 yes, throw it down.0056:10CAM-4 sink rate...sink rate...0056:12CAM-1 oh God.

0056:12TWR is that State on ground control?

0056:12CAM-2 you're gonna make it.0056:12CAM-1 OK.0056:13CAM-4 ...sink rate...
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0056:13CAM-2 flaps?0056:14CAM-4 ...sink rate...0056:17CAM-1 put 'em down.0056:18CAM-2 ***.0056:20CAM-1 whata we got?.0056:21CAM-2 we're still flying.0056:21CAM-1 OK.0056:22CAM-4 ...sink rate...sink rate.0056:23CAM-1 God #.0056:23CAM-2 keep goin', you're gonna make it.0056:24CAM-4 ...sink rate...0056:25CAM-2 keep coming.

0056:25TWR wind one seven zero at two two.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0056:26CAM-4 too low, flaps

0056:26RDO-2 yeah, call for emergency. call for 

0056:27CAM-4 terrain, terrain.

0056:30TWR they're comin' they're comin.

0056:30CAM-4 terrain.0056:31CAM-4 too low.0056:32CAM-2 you got it dude, you're gonna make it.0056:33CAM-1 OK.0056:34CAM-2 you got a long *..0056:35CAM-1 flaps, flaps forty. all the way down.0056:36CAM-4 don't sink.0056:37CAM-1 all the way, flaps forty.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0056:38CAM-2 they're all the way.0056:39CAM-1 OK, hold on guy.0056:40CAM [sound of impact]0056:41CAM [sound of horn]0056:42CAM-4 f-u-l-a-p-s.0056:44CAM [sound of vibration begins and continues for nine seconds]

0056:45TWR one seven zero at two two.

0056:46CAM-1 get it on, on the deck.0056:47CAM [sound of impact]0056:48CAM-1 hold it down buddy, hold it down, hold it down, hold it down,

hold it down...

0056:47CAM [sound of horn]0056:48CAM-1 ...hold it down.
INTRA-COCKPIT COMMUNICATION AIR-GROUND COMMUNICATI

TIME & TIME &SOURCE CONTENTSOURCE CONTENT0056:53CAM-2 God bless you, you made it.0056:55CAM [sound of horn]0056:56CAM-4 landing gear. [continues to the end of the recording]0056:59CAM [sound similar to engine RPM decreasing]0057:02CAM-1 shut down the motors.0057:04CAM-? throttles closed.0057:05CAM-2 pull 'em both.0057:06CAM-1 yeah, pull both fire handles.0057:06END of RECORDINGEND of TRANSCRIPT
128

APPENDIX C

AAL FLIGHT MANUAL EXCERPT ON

ALTIMETER SETTING PROCEDURES

SectIon 10 Approach and Landing

Page 14 Y

9/15/95 Flight Manual Part I ~

3.5

3.6

3.7

Descent During Approach

Radar vectors may provide course guidance to the final course or fix.

When operating on an unpublished route or while being radar vectored,

the pilot, when an approach clearance is received, shall maintain the last

altitude assigned until the aircraft is established on a segment of a

published route or instrument approach procedure unless a different

altitude is assigned by ATC. After the aircraft is so established,

published altitudes apply to descent within each succeeding route or

approach segment unless a different altitude is assigned by ATC. Upon

reaching the final approach course or fix, the pilot may complete the

instrument approach in accordance with a procedure approved for the

facility.

Radar Vectors

A. Comply with headings and altitudes assigned by the controller.

B. Question any assigned heading or altitude believed to be incorrect.

C. If compliance with any radar vector or altitude would cause a violation

of any FAR or create an unsafe situation, advise ATC and obtain a

revised clearance or instruction.

Altimeters

A. Descent

1. At airports where Above Field Level (QFE) settings are not available,

crews will convert Mean Sea Level (QNH) settings by application of

the appropriate conversion charts contained in the Performance

Section of the respective Operating Manual. (See Flight Manual Part

II for procedures at BOG, LPB, and UIO.)

2. On descent, after each Pilot has set the individual altimeter to

AFL(QFE) setting, a check will be made between the altitude

shown on each instrument and that shown on the third altimeter.

The difference should equal the published elevation of the airport

of intended landing.

3. Throughout the approach, monitor barometric changes and

correct the altimeters accordingly.

4. The Captain and FO should not reset altimeters simultaneously.

B. Approach

1. Altimeter callouts will be based on the Captain’s or FOS barometric altimeter (AFL) during the approach from the Final Approach

Fix on, except as follows:

a) Callouts for Category II and Ill approaches will be based upon

the radio altimeter from 300 feet on.

b) On all approaches, callouts from 50 feet to touchdown will be

based upon the radio altimeter.