In-Flight Left Engine Fire American Airlines Flight 1400 McDonnell

375 Pages·2009·1.99 MB·English

In‐Flight Left Engine Fire 
American Airlines Flight 1400 
McDonnell Douglas DC‐9‐82, N454AA 
St. Louis, Missouri 
September 28, 2007 

Accident Report
NTSB/AAR-09/03
PB2009-910403
National

Transportation

Safety Board
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NTSB/AAR-09/03
PB2009-910403
Notation 8087
Adopted April 7, 2009

Aircraft Accident Report
In-Flight Left Engine Fire
American Airlines Flight 1400
McDonnell Douglas DC-9-82, N454AA
St. Louis, Missouri
September 28, 2007

National
Transportation
Safety Board

490 L’Enfant Plaza, S.W.
Washington, D.C. 20594
National Transportation Safety Board. 2009. In-Flight Left Engine Fire, American Airlines Flight
1400, McDonnell Douglas DC-9-82, N454AA, St. Louis, Missouri, September 28, 2007. Aircraft
Accident Report NTSB/AAR-09/03. Washington, DC.

Abstract: This report explains the September 28, 2007, accident involving a McDonnell Douglas
DC-9-82, N454AA, operated as American Airlines flight 1400. The airplane experienced an in-flight
engine fire during departure climb from Lambert St. Louis International Airport, St. Louis, Missouri, and
the flight crew conducted an emergency landing. 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’
Continuing Analysis and Surveillance System. Safety recommendations concerning these issues are
addressed to the Federal Aviation Administration and American Airlines.

The National Transportation Safety Board (NTSB) is an independent Federal agency dedicated to promoting
aviation, railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is
mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents,
determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and
evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its
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mentioned in the report.
NTSB Aircraft Accident Report
Contents
Contents .......................................................................................................................................... i 
Figures ........................................................................................................................................... iv 
Abbreviations and Acronyms .......................................................................................................v 
Executive Summary ................................................................................................................... viii 
1. Factual Information ...................................................................................................................1 
1.1 History of Flight .........................................................................................................................1 
1.2 Injuries to Persons ......................................................................................................................5 
1.3 Damage to Airplane ...................................................................................................................5 
1.4 Other Damage ............................................................................................................................5 
1.5 Personnel Information ................................................................................................................5 
1.5.1 The Captain ......................................................................................................................5 
1.5.2 The First Officer ..............................................................................................................6 
1.5.3 Flight Attendants .............................................................................................................7 
1.6 Airplane Information .................................................................................................................7 
1.6.1 Pneumatic System ............................................................................................................7 
1.6.2 Engine Description ..........................................................................................................8 
1.6.2.1 Engine Start System ...........................................................................................8 
1.6.2.1.1 Company Manual Engine-Start Procedures ........................................... 12 
1.6.2.1.2 Manufacturer Manual Engine-Start Procedures ..................................... 13 
1.6.3 Hydraulic Power System ...............................................................................................13 
1.6.4 American Airlines’ Maintenance Program ....................................................................14 
1.6.5 American Airlines’ Continuing Analysis and Surveillance System ..............................15 
1.6.6 ATSV-Air Filter Maintenance and Inspection Procedures ............................................16 
1.6.6.1 American Airlines’ Maintenance and Inspection Procedures ..........................16 
1.6.6.2 Manufacturer Maintenance and Inspection Procedures ...................................17 
1.6.7 MD-80 Air Turbine Starter Valve Discrepancy History ...............................................17 
1.7 Meteorological Information .....................................................................................................19 
1.8 Aids to Navigation ...................................................................................................................19 
1.9 Communications ......................................................................................................................19 
1.10 Airport Information ................................................................................................................19 
1.11 Flight Recorders .....................................................................................................................20 
1.11.1 Cockpit Voice Recorder ..............................................................................................20 
1.11.2 Flight Data Recorder ....................................................................................................20 
1.12 Wreckage and Impact Information ........................................................................................20 
1.13 Medical and Pathological Information ...................................................................................22 
1.14 Fire .........................................................................................................................................22 
1.15 Survival Aspects ....................................................................................................................23 
1.15.1 Cockpit and Cabin Crew Communications .................................................................23 
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NTSB Aircraft Accident Report
1.15.2 Emergency Response and ARFF Personnel and Cockpit Communications ...............24 
1.16 Tests and Research .................................................................................................................26 
1.16.1 High-Temperature Exposure Fuel Fitting Tests ..........................................................26 
1.17 Organizational and Management Information .......................................................................28 
1.17.1 Flight Crewmember Training ......................................................................................28 
1.17.1.1 General Information .......................................................................................28 
1.17.1.2 Human Factors and Safety Training ..............................................................28 
1.17.2 Emergency and Abnormal Procedures ........................................................................30 
1.17.2.1 L or R Engine Start Valve Open Checklist ....................................................30 
1.17.2.2 Engine Fire/Damage/Separation Checklist ....................................................31 
1.17.2.3 Hydraulic Pressure- and Quantity-Related Checklists ...................................32 
1.17.2.4 One Engine Landing Checklist and Go-Around Procedures .........................32 
1.17.2.5 Emergency Landing Gear Extension Checklist .............................................33 
1.17.3 Emergency Evacuation Guidance ................................................................................33 
1.17.4 Fire Handle Retraction Guidance ................................................................................35 
1.18 Additional Information ..........................................................................................................37 
1.18.1 Postaccident Air Turbine Starter Valve Event .............................................................37 
1.18.1.1 Accident ATSV-Air Filter Assembly Examinations .....................................37 
1.18.1.2 Exemplar ATSV-Air Filter Assemblies Examinations ..................................39 
1.18.1.3 Additional PTI ATSV-Air Filter Tests ..........................................................39 
1.18.2 Multiple Emergencies Training ...................................................................................40 
1.18.2.1 FAA Position .................................................................................................40 
1.18.2.2 Boeing Position ..............................................................................................41 
1.18.2.3 American Airlines Position ............................................................................41 
1.18.2.4 Research on Crew Performance in Emergency and Abnormal Situations ....41 
1.18.3 Previous Related Safety Recommendations ................................................................42 
1.18.3.1 Safety Recommendation A-06-7....................................................................43 
1.18.3.2 Safety Recommendation A-07-9....................................................................43 
2. Analysis .....................................................................................................................................44 
2.1 General .....................................................................................................................................44 
2.2 Preflight Issues .........................................................................................................................45 
2.2.1 Preexisting Damaged ATSV-Air Filter .........................................................................45 
2.2.2 Intermittent Engine No-Start Condition ........................................................................45 
2.2.3 Use of Unapproved Manual Engine-Start Procedure ....................................................46 
2.3 Uncommanded ATSV Opening and Subsequent Left Engine Fire .........................................47 
2.3.1 Uncommanded Air Turbine Starter Valve Opening ......................................................47 
2.3.2 Left Engine Fire .............................................................................................................47 
2.3.2.1 Ignition Source .................................................................................................48 
2.3.2.2 Combustible Fluid Source................................................................................48 
2.4 Flight Crew Performance .........................................................................................................49 
2.4.1 Detection of and Response to the Left Engine ATSV-Open Light ...............................49 
2.4.2 Response to Left Engine Fire Warning and Subsequent Events ...................................52 
2.4.3 Decision to Go Around ..................................................................................................55 
2.4.4 Decision to Not Evacuate ..............................................................................................56 
2.4.5 Retraction of the Fire Handle ........................................................................................57 
2.5 Additional Human Factors-Related Issues ...............................................................................58 
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NTSB Aircraft Accident Report
2.5.1 Multiple Abnormal and Emergency Situations Training ...............................................58 
2.5.2 Nonpertinent Discussion and Cockpit Tone ..................................................................59 
2.5.3 Emergency Evacuation Preparedness ............................................................................61 
2.5.4 Flight and Cabin Crew Communication Issues .............................................................62 
2.6 Additional Maintenance Issues ................................................................................................63 
2.6.1 Air Turbine Starter Valve-Air Filters ............................................................................63 
2.6.2 Continuing Analysis and Surveillance System Program Deficiencies ..........................64 
3. Conclusions ...............................................................................................................................66 
3.1 Findings....................................................................................................................................66 
3.2 Probable Cause.........................................................................................................................68 
4. Safety Recommendations ........................................................................................................69 
Board Member Statement ...........................................................................................................71 
5. Appendixes ...............................................................................................................................74 
Appendix A: Investigation and Public Hearing .............................................................................74 
Appendix B: Cockpit Voice Recorder Transcript ..........................................................................75 
Appendix C: Combustible Fluid Source ......................................................................................362 
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NTSB Aircraft Accident Report
Figures
Figure 1. Photograph of the left side of the airplane after fire-extinguishing efforts were
completed. ...................................................................................................................... 4 
Figure 2. Schematic of the engine start system. ............................................................................. 9 
Figure 3. Schematic of the major components of the ATSV. ...................................................... 10 
Figure 4. Photograph of an exemplar ATSV-air filter. ................................................................ 11 
Figure 5. Photograph of the damaged ATSV-air filter housing, end cap, and lower fitting. ....... 38 
Figure 6. Photograph of the damaged ATSV-air filter housing and remaining filter material. ... 39 
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NTSB Aircraft Accident Report
Abbreviations and Acronyms
AC advisory circular
AFFF aqueous firefighting foam
AGB accessory gearbox
agl above ground level
AMM aircraft maintenance manual
AOL all operators letter
AOM aircraft operating manual
APU auxiliary power unit
AQP Advanced Qualification Program
ARFF aircraft rescue and firefighting
ASRS Aviation Safety Reporting System
ATBT action to be taken
ATC air traffic control
ATCT air traffic control tower
ATS air turbine starter
ATSV air turbine starter valve
v
NTSB Aircraft Accident Report
C Celsius
CAM cockpit area microphone
CASS Continuing Analysis and Surveillance System
CFR Code of Federal Regulations
CMM component maintenance manual
CPAP continuous positive airway pressure
CRM crew resource management
CVR cockpit voice recorder
DFGS digital flight guidance system
DFW Dallas/Fort Worth International Airport
EAS Emergency and Abnormal Situations
F Fahrenheit
FAA Federal Aviation Administration
FAM flight attendant manual
FCOM flight crew operating manual
FDR flight data recorder
FOM flight operations manual
IC incident commander
vi