MCDONNELL DOUGLAS DC-9-82 (MD-82)American Airlines
St. Louis, MO, USA · 2007-09-28·N454AA
What happened
NTSB summary, verbatimThe Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-09-03. On September 28, 2007, about 1313 central daylight time, American Airlines flight 1400, a McDonnell Douglas DC 9 82, N454AA, experienced an in flight left engine fire during departure climb from Lambert St. Louis International Airport (STL), St. Louis, Missouri. During the return to STL, the nose landing gear failed to extend, and the flight crew executed a go around, during which the crew extended the nose gear using the emergency procedure. The flight crew conducted an emergency landing, and the 2 flight crewmembers, 3 flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage due to the fire. The scheduled passenger flight was operating under the provisions of the 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
Photographs
1the aircraft, and what the investigators foundProbable cause
the Board's determinationAmerican Airlines’ maintenance personnel’s use of an inappropriate manual engine start procedure, which led to the uncommanded opening of the left engine air turbine starter valve, and a subsequent left engine fire, which was prolonged by the flight crew’s interruption of an emergency checklist to perform nonessential tasks. Contributing to the accident were deficiencies in American Airlines’ Continuing Analysis and Surveillance System program.
Safety recommendations
9 issuedwhat changed because of this accidentTO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the history of uncommanded air turbine starter valve (ATSV)-Open events in the MD-80 fleet and the effectiveness of coupling the ATSV-Open light to the Master Caution system to determine whether all MD-80 airplanes need to be modified to couple the ATSV-Open light to the Master Caution system. Once the evaluation is completed, require any necessary modifications.
TO THE FEDERAL AVIATION ADMINISTRATION: Require principal operations inspectors to review their operators’ pilot guidance and training on task allocation and workload management during emergency situations to verify that they state that, to the extent practicable, the pilot running the checklists should not engage in additional nonessential operational tasks, such as radio communications.
TO THE FEDERAL AVIATION ADMINISTRATION: Require MD-80 series airplane operators to incorporate information about the relationship between the pneumatic crossfeed valve and the engine fire handle into their training programs and written guidance.
TO THE FEDERAL AVIATION ADMINISTRATION: Establish best practices for conducting both single and multiple emergency and abnormal situations training.
TO THE FEDERAL AVIATION ADMINISTRATION: Once the best practices for both single and multiple emergency and abnormal situations training asked for in Safety Recommendation A-09-24 have been established, require that these best practices be incorporated into all operators’ approved training programs.
TO THE FEDERAL AVIATION ADMINISTRATION: Require that operators provide pilots with guidance requiring that pilots and flight attendants actively monitor exit availability and configure the airplane and cabin for an evacuation when the airplane is stopped away from the gate after a significant event to help expedite an emergency evacuation if one becomes necessary.
TO THE FEDERAL AVIATION ADMINISTRATION: Revise Advisory Circular 120-48, Communication and Coordination Between Flight Crewmembers and Flight Attendants, to update guidance and training provided to flight and cabin crews regarding communications during emergency and unusual situations to reflect current industry knowledge based on research and lessons learned from relevant accidents and incidents over the last 20 years.
TO THE FEDERAL AVIATION ADMINISTRATION: Require Boeing to establish an appropriate replacement interval for air turbine starter valve air filters installed on all MD-80 series aircraft.
TO AMERICAN AIRLINES: Evaluate your Continuing Analysis and Surveillance System program to determine why it failed to (1) identify deficiencies in its maintenance program associated with the MD-80 engine no-start failure and (2) discover the lack of compliance with company procedures. Then, make necessary modifications to the program to correct these shortcomings.
Sequence of events
8 timed eventsfrom the FDR factual report · claude-fable-5-1 (in-session)- 13:07:13.0 CDTpre-flightp.3FDR powered and recording for the event flight; takeoff flap 8.4 degrees
- 13:12:22.4 CDTtakeoffp.3Gear weight-on-wheels transitioned from Ground to Air (takeoff)
- 13:13:54.7 CDTclimbp.3Engine 1 fire warning transitioned from Off to On, 1 minute 32 seconds after liftoff
- 13:16:59.0 CDTclimbp.3FDR lost power (first gap, 22 seconds)
- 13:17:21.0-13:17:24.5 CDTreturnp.3FDR powered for 3.5 seconds, then lost power again (second gap, 12 minutes 12.5 seconds)
- 13:29:37.0 CDTapproachp.3FDR powered and recording again; Eng1 N1 and N2 recorded out-of-range values (set to 999) from this point
- 13:32:19.4 CDTlandingp.3Gear WOW transitioned from Air to Ground (landing) with flaps at 6.0 degrees; flap position then continued increasing for 56 seconds to 27.1 degrees and stayed there
- 14:01:39.6 CDTgroundp.3End of FDR data
NTSB analysis
from the final reportThe Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-09-03. On September 28, 2007, about 1313 central daylight time, American Airlines flight 1400, a McDonnell Douglas DC 9 82, N454AA, experienced an in flight left engine fire during departure climb from Lambert St. Louis International Airport (STL), St. Louis, Missouri. During the return to STL, the nose landing gear failed to extend, and the flight crew executed a go around, during which the crew extended the nose gear using the emergency procedure. The flight crew conducted an emergency landing, and the 2 flight crewmembers, 3 flight attendants, and 138 passengers deplaned on the runway. No occupant injuries were reported, but the airplane sustained substantial damage due to the fire. The scheduled passenger flight was operating under the provisions of the 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.