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CAUSE OF MD-80 ENGINE FIRE LINKED TO MAINTENANCE AND FLAWED SAFETY MANAGEMENT SYSTEM, NTSB SAYS



Title: CAUSE OF MD-80 ENGINE FIRE LINKED TO MAINTENANCE AND FLAWED SAFETY MANAGEMENT SYSTEM, NTSB SAYS

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                      NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: April 7, 2009
SB-09-14

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CAUSE OF MD-80 ENGINE FIRE LINKED TO MAINTENANCE AND FLAWED
SAFETY MANAGEMENT SYSTEM, NTSB SAYS

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The National Transportation Safety Board determined today
that an 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.

On September 28, 2007, at 1:13 p.m. CDT, American Airlines
flight 1400, a McDonnell Douglas DC-9-82 (MD-82), N454AA,
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). 

"The airline's own internal maintenance system, the purpose
of which is to catch maintenance and mechanical issues that
could lead to an incident or accident, failed to do what it
was designed to do," said Rosenker. "And that allowed this
sequence of events to get rolling, which ultimately resulted
in the accident. Following the appropriate maintenance
procedures would have gone a long way toward preventing this
mishap." 

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.

A synopsis of the Board's report, including the probable
cause, conclusions, and recommendations, is available on the
NTSB's website, at http://ntsb.gov/events/Boardmeeting.htm .
The Board's full report will be available on the website in
several weeks.

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NTSB Media Contact: Peter Knudson
(202) 314-6100
peter.knudson@xxxxxxxx

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