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Tangle of errors, misjudgment behind crash of Flight 1420

by ANDREA HARTER | March 18, 2001 at 5:08 a.m.

— Capt. Richard Buschmann made his share of mistakes the night American Airlines Flight 1420 crashed in a storm at Little Rock, but new information shows that direct action -- or inaction -- by others affected the jet's fate.

Recently obtained depositions and internal American documents indicate that a series of unfortunate events and judgments contributed to the June 1, 1999, accident.

  • More than 900 bolts of lightning struck near Little Rock National Airport, Adams Field, in the 15 minutes before the plane crashed, but the airline's dispatcher in Fort Worth didn't look at the monitor that would have told him that.
  • The Federal Aviation Administration's weather observer at the Little Rock airport had reported a thunderstorm in progress 28 minutes before the plane touched down. Three minutes before landing, rain had made the storm a bigger threat, but the observer's computer was resetting itself and couldn't transmit that fact.
  • The airplane itself had elaborate weather-reporting tools, capable of providing better information to the pilot than the monitors at American's operations center in Fort Worth. But the rookie co-pilot had the radar pointed at the wrong angle to accurately measure the danger of the storm.
  • American's meteorology department issued a thunderstorm warning for Arkansas before the plane left Dallas/Fort Worth International Airport. But the weathermen did not warn that the Little Rock airport was in the path of the storm, because company policy forbids that.

Flight 1420, with 139 passengers and a crew of six, touched down at 11:50, as a storm was breaking. Pilot Buschmann landed at an angle in a strong crosswind, pulled back harder than recommended on the reverse thrusters that slow the plane and never gained control on the wet runway. The plane did not stop, but swerved at the end of the runway, striking a set of concrete landing poles and pitching over a 25-foot embankment. It crunched its way through 250 feet of a steel walkway, breaking apart and burning on a bank of the Arkansas River. Eleven people died, including Buschmann.

Twenty-two months later, the National Transportation Safety Board is still investigating the cause of the crash, with no firm indication when it will be done.

After claiming for 18 months that it was not at fault, American accepted blame for the crash in December. The company wants to avoid a punitive-damages trial and contends that, now that it has accepted responsibility, there is no need for one.

The airline has been paying premium amounts lately in settlements with the passengers who have sued it -- up to five times what it was offering in earlier settlements-- and only a few passengers still insist they will seek punitive damages, which are meant to punish a wrongdoer.

Given the rate of settlements -- at least 15 in the past two months -- American was confident the case of Flight 1420 would end quietly. But a company memo and a safety complaint by one of American's meteorologists now has people talking.

Office memo No. 2674, issued Dec. 28, 1994, by the head of the meteorology department, limited the information American's weathermen could give out about thunderstorms at airports where its planes were landing.


There were several opportunities for Buschmann to learn that he was about to land in a driving thunderstorm.

Some of the most up-to-date information comes from Global Atmospherics' National Lightning Detection Network, which updates its reports to American's operations center every 30 seconds.

The network counted 903 cloud-to-ground lightning strikes within 20 miles of the geometric center of Little Rock National Airport between 11:36 and 11:51 on June 1, 1999, according to a safety board report issued last year.

American Airlines dispatcher Bill Trott in Fort Worth would have known that -- if he'd clicked the lightning icon on one of his three computers' screens, or if he'd looked at the big-screen monitor behind his work station.

When Trott was deposed over four days in April and May, he testified that he last remembered looking at a radar report on Flight 1420 between 11:18 and 11:23. He didn't recall the last time he looked at the lightning data.

"I was not aware that lightning was on the field at Little Rock," he said.

In Little Rock, Carol Burgess and Claude Johnson saw the lightning and heard the thunder firsthand. They work for Met-Tech Inc., which observes weather at the airport for the FAA.

At 11:23, as Flight 1420 was over southern Arkansas, Burgess' equipment issued an automatic special report to the National Weather Service that the wind had shifted. Burgess added the observation that a thunderstorm had begun. She noted cloud-to-cloud lightning; visibility, she observed, had declined from 10 miles to seven.

In Fort Worth, Trott testified, he received that weather information but did not act or tell the pilot, because the report did not mention rain.

In Little Rock, trace amounts of rain began falling at 11:24, but not enough to trigger another special report.

Flight 1420 flew on.

Johnson relieved Burgess about 11:45. The rain was steadily increasing, and, in the next five minutes, the Lightning Detection Network counted 46 cloud-to-ground strikes within five miles of the terminal.

At 11:46, Kenneth Kaylor, the air-traffic controller in the airport tower, warned Flight 1420 of heavy rain. "Aw, we're goin' right into this," Buschmann said to co-pilot Michael Origel.

At this point, dispatcher Trott knew of the thunderstorm but not the rain. Pilot Buschmann knew of the rain, but not the thunderstorm. Neither had both pieces of information.

American's rules prohibit landing in a thunderstorm with rain.

Meanwhile, FAA observer Johnson's equipment issued another special report at 11:47. He added his own observation: Visibility had suddenly dropped from seven miles to one mile.

As fate would have it, however, Johnson's equipment was just beginning a sweep of its sensors to update its data, a task it does every hour. During the six minutes that process takes, communications are locked down. So the special report could not be transmitted until 11:53.

By then, Flight 1420 was in pieces and burning.


According to his testimony, Trott checked the Internet and the Weather Channel before going to work at 10 that night. He talked with the dispatcher he was relieving and found that he was assigned to two dispatch desks, responsible for two major hubs, Dallas/Fort Worth and O'Hare in Chicago, and 20-30 planes, most already in the air.

American's meteorology department routinely briefs dispatchers three times a day -- but not at the late-night "graveyard" shift change. Dispatchers can ask the weather department for a briefing any time, but Trott did not do so that night.

"I felt totally briefed before I took the shift," Trott told the safety board in January 2000. "I didn't feel the need to further consult."

The thunderstorms in Arkansas were a concern when he approved Flight 1420's flight plan at 10:05.

Trott testified that he ordered the plane to be loaded with plenty of fuel, so it would have lots of options if the weather worsened. The plane had 35 minutes' worth of extra fuel in case it got held up on the taxiway at Dallas/Fort Worth. It had another 45 minutes' worth in case the pilot had to hold his position in the sky or divert. Trott said he'd wanted to give the plane even more holding fuel, but the flight-planning computer wouldn't let him; the plane would have been too heavy to land.

At that point, Trott expected Flight 1420 would get to Little Rock by 11:36, more than an hour before he expected the storm to hit.

The plane left Dallas/Fort Worth at 10:50. Four minutes later, after looking at 15-minute-old radar data, Trott messaged Buschmann and Origel to hurry to "beat the storms to Little Rock, if possible."

At 10:58, the National Weather Service's aviation forecaster in North Little Rock, Greg Meffert, changed the forecast for Little Rock airport, reporting that thunderstorms marching across Arkansas were worse, and moving faster, than forecast earlier.

Trott didn't get that updated forecast, but later testified he didn't need it: "I believe the crew and I were aware of the -- the situation that would impact Little Rock eventually."

Fifty feet away from Trott's desk in the operations center in Fort Worth, meteorologist Milo Milovich was about to end his shift. Milovich said in interviews that he briefed his replacement about the building storm, which he said was growing more intense as it neared Little Rock.

Milovich did not know about Flight 1420, only that the weather system he had followed for eight hours was expected to cross the airport in Little Rock between 11:30 and midnight.

Flight 1420 was racing the storm, though no one knew it.

An air-traffic controller in Fort Worth lengthened the plane's trip by rerouting it around the southern end of the storm. The plane flew practically due east from Dallas/Fort Worth, then took a left turn north at El Dorado, following the controller's instructions.

Trott didn't know that then, but, in his deposition, he estimated that decision cost Flight 1420 three to five minutes.

In the airplane, it was mostly co-pilot Origel's job to monitor the weather, but he had been in the cockpit of a passenger jet just six months and had never flown into such bad weather.

His on-board radar, made by the Honeywell Corp., can operate in either "map mode" or "weather mode." Set to weather mode, it shows green shades for rain, yellow for heavier activity and red for intense storms.

Origel testified in March 2000 that the radar was in the weather mode once the crew reached cruising altitude.

Both he and Buschmann adjusted the radar as they tried to gauge the weather, although Origel could not recall the exact settings. A pilot who had flown the plane earlier that day testified that the radar had displayed the weather in a range as broad as 160 miles or as fine as 20 miles.

The pilots must have been using the higher ranges at some point; Origel said they saw the bulk of the storm on radar when they were just a minute or two north of El Dorado, about 80 miles from Little Rock. "I don't like that ... that's lightning," Origel said, according to a transcript of the cockpit voice recording.

The radar is in the nose of the plane. It sweeps side-to-side, and the direction of the sweep can be adjusted up or down 10 degrees.

Origel said his radar was pointed down. But experts and pilots who are experienced with the MD-82 said pointing the radar down at wet ground should have produced a red screen, as the radar waves would have reflected a solid surface.

Origel said he did not adjust the radar upward as the plane began descending, even though they were entering some clouds. In hindsight, he testified, Flight 1420 must already have been beneath the bottom edge of the storm.

Origel said he never saw a red signal on the radar, or even a yellow one, only green. During his deposition a year ago, he couldn't explain why the National Weather Service's radar showed red for the same time and area. Back in Fort Worth, Milovich says, his computer was showing red, too.

"Would you agree with me, if you'd have tilted the radar up, it would have lit up [red] like a Christmas tree?" Fort Worth attorney Bob Bodoin asked Origel.

"In retrospect, it probably would have," the co-pilot said, adding later that "if we had a radar picture like [the Weather Service's picture] in the cockpit, we wouldn't have attempted to land."

Dispatcher Trott, too, testified that he knew if the storm and the plane arrived in Little Rock at the same time, there would be trouble. But he said he didn't know exactly where either was between 11:30 and the time the plane touched down.

Buschmann had planned to land on runway 22L, northeast to southwest, but found he could not see the runway clearly because of clouds. Moreover, the wind had shifted, and he needed to land into the head wind. He asked to be redirected to runway 4R, southwest to northeast.

Buschmann adjusted his course, costing Flight 1420 another three to five minutes.

The plane landed at 11:50. "We're down," Origel said. "We're sliding."


American Airlines has the largest meteorology department of any aviation company, with a $2 million budget to support 20 meteorologists and two managers, who are also weather forecasters. Most airlines don't spend money on in-house weather personnel.

American's weather department is so big, the airline is the only one given FAA approval to use its own weather technology and expertise to advise pilots and dispatchers.

Its policies-and-procedures manual is called the Enhanced Weather Information System. In the case of a thunderstorm, it says, "a forecast of significant adverse weather phenomena affecting a ground station ... will immediately be issued."

"[I]t is the policy of the Company not to enter or depart terminal areas when such areas are blanketed by thunderstorms. ... Airborne radar equipment and all available weather reports will be utilized to make this determination."

But American's Office Memo 2674, issued Dec. 28, 1994, by American's manager of weather services, Warren Qualley, runs counter to this.

It says the meteorology department's bulletins "will no longer address thunderstorm activity" at airport terminals, declaring that a broader bulletin, which forecasts the general location and velocity information about "areas of congested thunderstorm activity," would be sufficient for the needs of pilots and dispatchers.

Moreover, those broader bulletins would no longer be issued simply because the National Weather Service had declared a tornado and severe thunderstorm watch. The memo noted that the Weather Service issued so many of those that they had become "confusing" and that many had "little potential for aircraft routing disruption."

Qualley wrote: "I feel that these changes should significantly improve the communication of information about thunderstorms to the dispatchers and flight crew."

According to Qualley's testimony in an August deposition, American now reports the Weather Service's thunderstorm watches. But the company has confirmed that it has not reinstated the thunderstorm-at-a-terminal report.

Meteorologist Milovich says memo 2674 prevented him from warning the pilot of Flight 1420 about the storm hitting Little Rock.

In February 2000, he complained to the head of American's System Operations Center that "I find it more than somewhat disconcerting that no changes have been made or, it seems even considered, in the way Meteorology provides [terminal bulletins], since the Little Rock accident."

Milovich, a American Airlines meteorologist since 1989, has complaints about many management or safety issues, which he has voiced to company officials ranging from Chairman Don Carty to Qualley, his immediate boss. He has sent copies of some to American's corporate board and the safety board. He has registered with the Department of Transportation as a whistle-blower.

American declined to discuss Milovich beyond issuing a statement that the company "has conducted an independent internal investigation into Mr. Milovich's allegations which resulted in no information substantiating the charges."

"To further debate these issues in the media could lead to an inadvertent violation of the National Transportation Safety Board rules governing the conduct of parties involved in the Flight 1420 investigation," the company said.

On Feb. 12, Tim Ahern, vice president of American's safety department, wrote Milovich that the company "found no evidence of any safety violations," adding that it was "our understanding that the [National Transportation Safety Board] does not consider the issues you raised to be safety concerns."

Paul Schlamm, an NTSB spokesman, disputed that. "We have received Mr. Milovich's documents and do consider them a part of the Flight 1420 investigation," he told the Arkansas Democrat-Gazette.

Milovich was granted unpaid medical leave of absence in October after his doctor wrote that he was suffering from stress, later revising that diagnosis to post-traumatic stress disorder caused by Flight 1420's crash.


A slide presentation viewed last month at American's operations center said the meteorology department "provides the latest weather information to dispatch and flight crews in real time," monitors the weather watch information, and "issues weather alerts for all affected areas and airports."

Questioned about that, insiders at American said they might change the slides. The weather department's main job, they said, is to supply information that helps the airline route its planes and gauge fuel needs.

But plaintiffs' lawyers pressed Qualley about the department's safety functions when they deposed him in August.

"Do you agree that the mission of the weather department is to collect and disseminate weather information so that this information can be used in order to keep the airplanes out of dangerous weather?" Chicago attorney David Rapoport asked.

Qualley: "Well, as I said, I -- I don't agree with that specific statement. All I'm saying is that we collect and disseminate weather information to various users, and my assumption would be that it is being used to enhance safety."

Later, Rapoport asked, "Safety is primarily why you exist, correct?"

Qualley: "We exist for a number of reasons, but safety is the underpinning of the whole thing. I think I can phrase it that way."

Qualley, a 22-year company veteran, is on the safety board team investigating the weather on June 1, 1999. He testified that he has spent at least two hours on the investigation.

He said he was convinced that only one bolt of lightning struck the airport the night Flight 1420 crashed, and that the plane did not encounter a thunderstorm.

Qualley was not questioned about his memo blocking terminal bulletins about thunderstorms.

The attorneys say now that they didn't know the memo existed.

Copyright © 2001, Arkansas Democrat-Gazette, Inc. All rights reserved.


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