Also Cites "Flawed Internal Safety Management System" At
AAL
The National Transportation Safety Board determined Tuesday a
September 2007 engine fire on an American Airlines jetliner was
probably due to an unapproved and improper procedure used by
mechanics to manually start one of the engines. The fire was
prolonged and the safety of the aircraft further jeopardized by how
the flight crew handled the emergency.
A flawed internal safety management system, which could have
identified the maintenance issues that led to the accident, was
cited as a contributing factor by the Board.
As ANN reported, on the afternoon of September
28, 2007 American Airlines flight 1400, a McDonnell Douglas DC-9-82
(MD-82), experienced an in-flight left engine fire during departure
climb from the Lambert-St. Louis International Airport (STL).
During the return to STL, the nose landing gear failed to extend,
and a go-around was executed. The flight crew conducted an
emergency landing, and the two flight crewmembers, three flight
attendants, and 138 passengers deplaned on the runway. No occupant
injuries were reported, but the airplane sustained substantial
damage.
The investigation revealed that a component in the manual start
mechanism of the engine was damaged when a mechanic used an
unapproved tool to initiate the start of the #1 (left) engine while
the aircraft was parked at the gate at STL. The deformed mechanism
led to a sequence of events that resulted in the engine fire, to
which the flight crew was alerted shortly after take-off.
The Board examined how the flight
crew handled the in-flight emergency and found their performance to
be lacking. The captain did not adequately allocate the numerous
tasks between himself and the first officer to most efficiently and
effectively deal with the emergency in a timely manner. The Board
was particularly concerned with how the crew repeatedly interrupted
their completion of the emergency checklist items with lower
priority tasks.
"Here is an accident where things got very complicated very
quickly and where flight crew performance was very important," said
NTSB Acting Chairman Mark V. Rosenker. "Unfortunately, the lack of
adherence to procedures ultimately led to many of this crew's
in-flight challenges."
In examining the maintenance issues, investigators found that in
the 13 days prior to the accident flight, the aircraft's left
engine air turbine starter valve had been replaced a total of six
times in an effort to address an ongoing problem with starting the
engine using normal procedures. None of valve replacements solved
the engine start problem and the repeated failures to address the
issue were not recognized or discovered by the airline's Continuing
Analysis and Surveillance System (CASS).
As a result of the investigation, the Safety Board issued a
total of nine safety recommendations. The Board asked the Federal
Aviation Administration (FAA) to 1) evaluate the history of air
start-related malfunctions in MD-80 airplanes to determine if
changes to the cockpit warning system are warranted; 2) ensure that
pilots are trained to refrain from interrupting the completion of
emergency checklists with nonessential tasks; 3) ensure that MD-80
operators train crews on the interaction of systems involved in
engine fire suppression; 4) and 5) ensure that crews are trained to
handle multiple emergencies simultaneously; 6) require that crews
be trained to prepare the aircraft for an emergency evacuation
after a significant event away from the gate; 7) provide flight and
cabin crews with the latest guidance on effective communications
during emergencies; and 8) require Boeing to establish an interval
for servicing an engine component.
The Board also recommended that American Airlines evaluate and
correct deficiencies in its CASS program.