St. Louis, Missouri
September 28, 2007
NTSB Number: AAR-09-03
NTIS Number: PB2009-910403
Adopted April 7, 2009
On September 28, 2007, about 1313 central daylight time, American Airlines flight 1400, a McDonnell Douglas DC-9-82, N454AA, experienced an in-flight 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 from the fire. The scheduled passenger flight was operating under the provisions of 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.
The National Transportation Safety Board determines that the probable cause of this accident was American 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 (CASS) program.
The safety issues discussed in this report relate to the following: characteristics of the "Air Turbine Starter Valve (ATSV) Open" light; emergency task allocation guidance; guidance and training on the interrelationship between pneumatic crossfeed valves and engine fire handles; multiple simultaneous emergencies training; guidance on evacuation preparation on the ground; guidance and training on communications between flight and cabin crews during emergency and unusual situations; ATSV-air filter replacement intervals; and American Airlines' CASS. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration and American Airlines.
As a result of the investigation of this accident, the National Transportation Safety Board makes the following recommendations.
To 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. (A-09-21)
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 nonessential operational tasks, such as radio communications. (A-09-22)
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. (A-09-23)
Establish best practices for conducting both single and multiple emergency and abnormal situations training. (A-09-24)
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. (A-09-25)
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. (A-09-26)
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. (A-09-27)
Require Boeing to establish an appropriate replacement interval for air turbine starter valve-air filters installed on all MD-80 series aircraft. (A-09-28)
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. (A-09-29)