San Juan, Puerto Rico
July 9, 1998
Adopted November 16, 1999
On July 9, 1998, about 1007 Atlantic standard time, an Airbus Industrie A300B4-605R, N80057, registered to General Electric Aircraft Engines and operated by American Airlines, Inc. (AA), as flight 574, had a fire in the No. 1 engine shortly after takeoff from Luis Munoz Marin International Airport, San Juan, Puerto Rico. The airplane received minor damage. The captain, first officer, 7 flight attendants, and 215 passengers were not injured. Twenty-eight passengers reported receiving minor injuries during the post-landing emergency evacuation. The airplane, operated by AA as a scheduled passenger flight under the provisions of Title 14 Code of Federal Regulations Part 121, was destined for Miami, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan had been filed.
The National Transportation Safety Board determines the probable causes of this incident were: an in-flight engine fire resulting from (1) the failure of the engine overhaul facility to install, and the failure of American Airlines to ensure installation of, the proper adapter bolt insert to preclude fuel leakage and the failure of the engine overhaul facility to notify the aircraft operator and the engine manufacturer, and request correction, of an error in Service bulletin 72-743; and (2) the failure of General Electric Aircraft Engines to specify the proper adapter bolt and to correct (SB) 72-743 after notification of the error. Contributing to the severity of the incident was (1) the flight crew's failure immediately to complete the in-flight engine fire procedures; and (2) the failure of Airbus Industries and American Airlines to provide all necessary information in the in-flight engine fire procedures.
The National Transportation Safety Board recommends that the Federal Aviation Administration:
Discontinue the practice of allowing inadvertent and actual slide or slide/raft deployments to be used as a method of demonstrating compliance with an air carrier's, FAA-approved maintenance program. (A-99-XX)
For a 12-month period, require that all operators of transport-category aircraft demonstrate the on-airplane operation of all emergency evacuation systems (including door opening assist mechanisms and slide or slide/raft deployment) on 10 percent of each type of airplane (minimum of one airplane per type) in their fleets. These demonstrations should be conducted on an airplane in a controlled environment so that the entire evacuation system can be properly evaluated by qualified personnel. The results of the demonstration program (including an explanation of the reasons for any failures) should be documented for each component of the system and should be reported to the FAA. (A-99-XX)
Revise the requirements for evacuation system operational demonstrations and maintenance procedures in air carrier maintenance programs to improve the reliability of evacuation systems on the basis of an analysis of the demonstrations recommended in Safety Recommendation A-99-XX. Participants in the analysis should include representatives from aircraft and slide manufacturers, airline operators, and crewmember and maintenance associations. (A-99-XX)
Based on reports of component or system failures discovered in the demonstration program recommended in SR A-99-XX, establish an effective method of identifying recurring or potentially recurring failure modes and ensuring that those failures are adequately addressed by issuing airworthiness directives or taking other appropriate actions. (A-99-XX)
Ensure that all personnel accomplishing any installation, repair, or inspection of the emergency evacuation systems, receive training to ensure that they have proper knowledge of the operation and installation of the systems. (A-99-XX)