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 . 6638B m *%L’bww*&*+ ‘. ‘. - .,, -. --3 The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. 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Washington, D.C. 20594 (202)314-6551 (800)877-6799 Safety Board publications may be purchased, by individual copy or by subscription, from: National Technical Information Service 5285 Port Royal Road Springfield, Virginia 22161 (703)487-4600 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. 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 iii 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 .......................................................