Narrative:American Airlines flight 1400, a DC-9-82, N454AA, experienced an in-flight engine fire during departure climb from Lambert-St. Louis International Airport (STL). 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.
Probable Cause:
PROBABLE CAUSE: "The National Transportation Safety Board determines that the probable cause of this accident was American Airlines maintenance personnels 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 crews interruption of an emergency checklist to perform nonessential tasks. Contributing to the accident were deficiencies in American Airlines Continuing Analysis and Surveillance System program."
Accident investigation:
|
Investigating agency: | NTSB |
Status: | Investigation completed |
Duration: | 1 year and 6 months | Accident number: | NTSB AAR-09/03 | Download report: | Final report
|
|
Classification:
Engine fire
Forced landing on runway
Sources:
»
SKYbrary » NTSB
Follow-up / safety actions
NTSB issued 9 Safety Recommendations
Issued: 19-MAY-2009 | To: FAA | A-09-21 |
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. (Closed - Acceptable Action) |
Issued: 19-MAY-2009 | To: FAA | A-09-22 |
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. (Closed - Acceptable Action) |
Issued: 19-MAY-2009 | To: FAA | A-09-23 |
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. (Open Acceptable Alternate Response) |
Issued: 19-MAY-2009 | To: FAA | A-09-24 |
Establish best practices for conducting both single and multiple emergency and abnormal situations training. (Closed - Unacceptable Action) |
Issued: 19-MAY-2009 | To: FAA | A-09-25 |
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. (Open - Acceptable Response) |
Issued: 19-MAY-2009 | To: FAA | A-09-26 |
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. (Closed - Unacceptable Action) |
Issued: 19-MAY-2009 | To: FAA | A-09-27 |
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. (Open - Acceptable Response) |
Issued: 19-MAY-2009 | To: FAA | A-09-28 |
Require Boeing to establish an appropriate replacement interval for air turbine starter valve-air filters installed on all MD-80 series aircraft. (Closed - Unacceptable Action) |
Issued: 19-MAY-2009 | To: American Airlines | A-09-29 |
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. (Closed - Acceptable Action) |
Show all...
Photos
accident date:
28-09-2007type: McDonnell Douglas DC-9-82
registration: N454AA
accident date:
28-09-2007type: McDonnell Douglas DC-9-82
registration: N454AA
accident date:
28-09-2007type: McDonnell Douglas DC-9-82
registration: N454AA
accident date:
28-09-2007type: McDonnell Douglas DC-9-82
registration: N454AA
accident date:
28-09-2007type: McDonnell Douglas DC-9-82
registration: N454AA
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does
not display the exact flight path.
Distance from Saint Louis-Lambert International Airport, MO to Chicago-O'Hare International Airport, IL as the crow flies is 412 km (258 miles).
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.