DCA07MA310

NTSB accident investigation · Mcdonnell Douglas DC-9-82 (MD-82) · St. Louis, MO · September 28, 2007

Accident · No injuriesClass 1 · MajorFinal report
Date
September 28, 2007, 13:16 local (18:16 UTC)
Place
St. Louis, MO
Injuries
143 uninjured
Damage
Substantial damage
Phase of flight
Enroute
Aircraft
N454AAMcdonnell Douglas DC-9-82 (MD-82)
Weather
Visual (VMC)
Status
Completed · report March 28, 2010
Report
Board-adopted at Board Meeting
Investigation class
Class 1
NTSB office
Major Investigations Division
Parties
FAA Washington, DC
Safety recommendations
Yes
FAA report
20070928832029A
Case key
66830

From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the accident.

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Probable cause

American Airlines’ maintenance personnel’s 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 crew’s interruption of an emergency checklist to perform nonessential tasks. Contributing to the accident were deficiencies in American Airlines’ Continuing Analysis and Surveillance System program.

Sequence of events

NTSB’s coding before 2008: each occurrence and phase of flight, and the causes and factors under it. The codes are defined in NTSB’s coding manual.

FireClimb
Turbine assembly
Procedure inadequateCompany maintenance personnelCause
Inadequate surveillance of operationCompany/operator mgmtCause
ChecklistFlightcrewCause
Miscellaneous/otherEmergency descent/landing

Analysis

The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-09-03.

On September 28, 2007, about 1313 central daylight time, American Airlines flight 1400, a McDonnell Douglas DC 9 82, N454AA, experienced an in flight left engine fire during departure climb from Lambert St. Louis International Airport (STL), St. Louis, Missouri. 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. The scheduled passenger flight was operating under the provisions of the 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

Factual narrative

The Safety Board's full report is available at http://www.ntsb.gov/publictn/A_Acc1.htm. The Aircraft Accident Report number is NTSB/AAR-09-03.

On September 28, 2007, about 1313 central daylight time, American Airlines flight 1400, a McDonnell Douglas DC 9 82 (MD 82), N454AA, experienced an in flight left engine fire during departure climb from Lambert St. Louis International Airport (STL), St. Louis, Missouri. 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. The scheduled passenger flight was operating under the provisions of the 14 Code of Federal Regulations Part 121 on an instrument flight rules flight plan. Visual meteorological conditions prevailed at the time of the accident.

On the day of the accident, the flight crew reported to duty about 1140 for a scheduled departure time of 1240. The captain was the pilot flying, and the first officer was the pilot monitoring.

During the initial attempt to start the engines, the left engine did not start, and the flight crew notified American Airlines maintenance personnel of the problem. At 1238:55, the cockpit voice recorder (CVR) recorded a mechanic informing the captain that maintenance personnel were ready to manually start the left engine. About 1241, the flight crew performed the Before Start checklist and the takeoff briefing. About 5 minutes later, maintenance personnel instructed the captain to initiate the manual engine start sequence by holding the engine start switch in the START position while the maintenance personnel manually opened the left engine’s air turbine starter valve (ATSV). The captain informed the mechanic that he saw no indication that the left engine’s ATSV had opened. About 1301, during the second attempt to start the left engine manually, the engine started. From about 1302 to 1308, the CVR recorded the flight crew engaging in nonpertinent conversation during the taxi for takeoff.

During postaccident interviews, the flight crew stated that, during the taxi for takeoff, all of the cockpit indications were normal, and no warning lights were illuminated. The flight crew reported that the takeoff was uneventful until the airplane reached an altitude of about 1,000 to 1,500 feet mean sea level (about 380 to 880 feet above ground level). At 1312:49, the first officer reported to air traffic control (ATC) that the airplane was passing through an altitude of about 1,500 feet, and shortly thereafter, the first officer stated that the Left Engine “ATSV Open” light had illuminated. At 1313:55, the CVR recorded a sound similar to the Engine Fire warning bell and then, the first officer stating that the Left Engine Fire warning light had illuminated. The captain stated that the flight would need to return to STL, and he then asked the first officer to contact STL and declare an emergency, and the first officer complied with the instruction. The STL departure controller asked the first officer the nature of the emergency and whether the flight crew wanted aircraft rescue and firefighting (ARFF) trucks to be waiting at the runway upon landing, and the first officer reported that it was a left engine fire and requested ARFF presence.

At 1314:49, the first officer began performing the Engine Fire/Damage/Separation checklist. After the first officer completed the first two items on the checklist, disconnecting the autothrottles and placing the left engine throttle to idle, the captain stated that he wanted to brief the flight attendants. After the first officer handled communications with ATC regarding the nature of the emergency, the captain transferred control of the airplane to the first officer. Then, the captain briefed the flight attendants about the situation and informed them that the airplane would be returning to STL. After the briefing, the captain resumed control of the airplane. At 1316:22, the first officer stated that the Left Engine Fire warning light was still illuminated, and he then resumed conducting the Engine Fire/Damage/Separation checklist. During postaccident interviews, the captain stated that, about this time, the airplane began to experience some electrical malfunctions, which resulted in the loss of the captain’s primary flight and navigation display panels.

At 1317:01, the CVR again recorded a sound similar to the Left Engine Fire warning bell followed by the first officer stating that the warning light was still illuminated. Fourteen seconds later, the fire warning alerted again, and, 4 seconds later, the first officer stated, “just got power transfer too.” At 1317:26, the CVR recorded the first officer stating, “I can’t even shut it off,” and 10 seconds later that he was pulling the fire handle, which subsequently fired the first fire bottle. At 1318:27, the first officer stated, “this will not discharge.” At 1319:07, he reported that both of the fire bottles were discharged. Subsequently, the CVR recorded the flight crew discussing preparing the flaps and landing gear for landing. Less than 1 minute later, the first officer stated, “we’ve lost all…power,” and the CVR recorded the flight crew discussing problems keeping the cockpit door closed.

At 1319:58, the captain instructed the first officer to lower the landing gear, and, subsequently, the CVR recorded a sound similar to the landing gear handle being operated followed by a sound similar to the spoiler handle being armed. At 1320:40, the STL air traffic control tower (ATCT) cleared the flight to land on runway 30R.

According to the CVR transcript, less than 1 minute later, the captain stated that he had tried to start the auxiliary power unit, which supplies the backup electrical power to the airplane systems, but that it would not start. He also stated that the landing gear position lights had not illuminated. Shortly thereafter, the captain asked the STL ATCT controller to verify whether or not the landing gear had extended. The tower controller reported that the nose landing gear was not extended, and the first officer responded that they were going to go around. Soon after, the STL ATCT controller informed the flight crew, “there was quite a bit of black…soot…on that engine so….the fire was real.”

During the go around, the flight crew continued to experience problems with the nose landing gear and electrical systems, and the captain asked an off duty company pilot to come to the cockpit to assist; this pilot arrived in the cockpit about 1323. The captain decided it would be best to land on the longest runway, runway 30L, which was 2,000 feet longer than runway 30R. At 1325:09, the captain asked the controller if the airplane could land on runway 30L, and the controller complied and cleared the flight to land on runway 30L.

At 1325:26, the off duty company pilot asked the captain if they were going to evacuate the airplane, and the captain replied, “not unless we have to.” Ten seconds later, the first officer began performing the Emergency Gear Extension checklist during the go around. While the first officer was performing the checklist, the off duty company pilot stated, “you’ve lost all…hydraulic pressure on the right side,” and the first officer responded, “how did that happen?” At 1326:25, the first officer announced that he had completed the checklist. The captain stated that, although none of the landing gear indications had illuminated, he heard noise similar to the sound of the nose gear being extended. The CVR also recorded increased background noise consistent with the sound of the landing gear extending.

At 1327:33, the captain stat

Aircraft

Registration
N454AA
Reported as
Mcdonnell Douglas DC-9-82 (MD-82)
Category
Airplane
Serial number
49559
Airframe hours
57,746
Engines
Pratt and Whitney JT8D-200, 20,850 lbs thrust, turbo fanPratt and Whitney JT8D-200, 20,850 lbs thrust, turbo fan
Damage
Substantial damage
Fire
In-Flight
Flight
Part 121
Operator
American Airlines
Registered owner
American Airlines
Airworthiness certificate
Standard, Transport
Last inspection
Continuous airworthiness · November 22, 2006
Departed
STL · St Louis, MO
Destination
ORD · Chicago, IL
Flight plan
Unknown
Airport
STL · Lambert-St. Louis Int Airport, runway 30L, 11,019 × 200 ft, concrete

Matched to the registry by N-number and the event date; the registry’s history has gaps, so older matches can be wrong. Compare the reported make and model.

Flight crew · 2

As NTSB recorded them. NTSB leaves out names.

Role
Co-pilot
Age
43
Injuries
None
Certificate
Commercial
Airplane ratings
Multi-engine land
Instrument ratings
Airplane
Medical
Class 2, Without waivers/limitations
Last flight review
May 16, 2007
Seat
Right
Flight hours
4,000 total · 3,004 in this make and model · 1,500 as pilot in command · 116 in the last 90 days · 69 in the last 30 days · 0 in the last 24 hours
Role
Pilot
Age
59
Injuries
None
Certificates
Private, Flight engineer, Airline transport
Airplane ratings
Single-engine land, Multi-engine land
Instrument ratings
Airplane
Medical
Class 1, With waivers/limitations
Last flight review
August 19, 2007
Seat
Left
Flight hours
14,000 total · 883 in this make and model · 6,000 as pilot in command · 127 in the last 90 days · 71 in the last 30 days · 0 in the last 24 hours

Weather

Conditions
Visual (VMC)
Wind
4 knots
Visibility
10 statute miles
Lowest ceiling
None
Temperature
82 °F, dew point 45 °F
Altimeter
30.20 inHg
Observed at
STL

Docket · 63

The files NTSB released with the investigation on October 30, 2008, on NTSB’s docket system: statements, records, photos and specialists’ reports. 79.0 MB in all.

Operations 2 - ATC transcriptItem 1 · .PDF · 2.7 MBOperations 2 - Factual Report of Group Chairman - 8-08-2008Item 2 · .PDF · 133 KBOperations 2 - Addendum 1 - to Operational Factors / Human Performance Factual ReportItem 3 · .PDF · 21 KBOperations 2 - Attachment 1 - Interview SummariesItem 4 · .PDF · 130 KBOperations 2 - Attachment 2 -Engine /Fire / Damage / Separation checklistItem 5 · .PDF · 131 KBOperations 2 - Attachment 3 - One Engine Landing checklistItem 6 · .PDF · 110 KBOperations 2 - Attachment 4 - Emergency Landing checklistItem 7 · .PDF · 110 KBOperations 2 - Attachment 5 - Emergency Gear Extension checklistItem 8 · .PDF · 67 KBOperations 2 - Attachment 6 - Flight Operations Technical BulletinItem 9 · .PDF · 124 KBOperations 2 - Attachment 7 - FAA Response to NTSB information request 08-087Item 10 · .PDF · 134 KBOperations 2 - Attachment 8 - Transcript of AARF Training VideoItem 11 · .PDF · 236 KBOperations 2 - Attachment 9 - Revised L or R Start Valve Open Light On procedureItem 12 · .PDF · 66 KBOperations 2 - Attachment 10 - Safety Alert for Operators - Fire Handle Characteristics, DC-9, MD-80, and MD-90 AirplanesItem 13 · .PDF · 114 KBOperations 2 - Errata 1 to Operational Factors/Human Factors factual reportItem 14 · .PDF · 28 KBOperations 2 - Addendum 2 to Operational Factors/Human Factors factual reportItem 15 · .PDF · 83 KBSurvival Factors 6 - Factual Report of Group ChairmanItem 16 · .PDF · 399 KBSurvival Factors 6 - Addendum to Survival Factors Factual Report - ARFF Re-Interview NotesItem 17 · .PDF · 55 KBSurvival Factors 6 - Attachment 1: STL Operations and Communications Center, Aircraft/Incident/Accident ReportItem 18 · .PDF · 119 KBSurvival Factors 6 - Attachment 2: STL Airport Police Department, Law Enforcement Offense/Incident ReportItem 19 · .PDF · 381 KBSurvival Factors 6 - Attachment 3: Airport Operations and Communications Center Electronic LogbookItem 20 · .PDF · 107 KBSurvival Factors 6 - Attachment 4: STL Airport DiagramItem 21 · .PDF · 308 KBSurvival Factors 6 - Attachment 5: STL ARFF Stand-by LocationsItem 22 · .PDF · 216 KBSurvival Factors 6 - Attachment 6: STL ARFF Staging Positions Around the AirplaneItem 23 · .PDF · 442 KBPowerplants 8 - Factual Report of Group Chairman - engineItem 24 · .PDF · 3.5 MBPowerplants 8 - Factual Report of Group Chairman -Addendum 1 - Engine Starting SystemItem 25 · .PDF · 3.0 MBPowerplants 8 - Attachment 1 STARTER SHUTOFF VALVES - MAINTENANCE PRACTICESItem 26 · .PDF · 45 KBPowerplants 8 - Attachment 2 - Boeing AMM Cranking Decription and OperationItem 27 · .PDF · 3.6 MBPowerplants 8 - Attachment 3 Boeing AOL 9-2549 Engine Starting SystemItem 28 · .PDF · 148 KBSystems 9 - Factual Report of Group ChairmanItem 29 · .PDF · 272 KBFlight Data Recorder 10 - Specialist's Factual ReportItem 30 · .PDF · 403 KBFlight Data Recorder 10 - Attachment 1 (FDR tabular data)Item 31 · .CSV · 10.7 MBMaintenance Records 11 - Factual Report of Group ChairmanItem 32 · .PDF · 172 KBMaintenance Records 11 - Attachment 2 Field Maintenance Report (FMR) print out for N454AAItem 33 · .PDF · 3.1 MBMaintenance Records 11 - Attachment 3 DC-9/MD-80 Boeing AMM Cranking Description and OperationItem 34 · .PDF · 417 KBMaintenance Records 11 - Attachment 4 Boeing AOL, Number 9-2549, dated December 16, 1997Item 35 · .PDF · 252 KBMaintenance Records 11 - Attachment 5 AA MPM MEL practices for starter shutoff valveItem 36 · .PDF · 273 KBMaintenance Records 11 - Attachment 7 GPM Chapter 02-23 Request for Services/Form E63Item 37 · .PDF · 216 KBMaintenance Records 11 - Attachment 8 MD Engineering Comments on Procedural ChangesItem 38 · .PDF · 127 KBMaintenance Records 11 - Attachment 9 Other Aircraft Start Valve Write-up between September 16- 28, 2007Item 39 · .PDF · 3.5 MBMaintenance Records 11 - Attachment 10 GPM Chapter 23 Surveillance 23-01 Reliability/Performance AnalysisItem 40 · .PDF · 711 KBMaintenance Records 11 - Attachment 11 GPM Chapter 23 Surveillance 23-21 Data AnalysisItem 41 · .PDF · 978 KBMaintenance Records 11 - Attachment 12 Left Engine Fuel & Filter – Clean/Replace Work Card 7751, dated 3/16/2006Item 42 · .PDF · 1.2 MBMaintenance Records 11 - Attachment 13 Right Engine Fuel & Filter – Clean/Replace Work Card 7752, dated 3/16/2006Item 43 · .PDF · 1.2 MBMaintenance Records 11 - Attachment 14 Left Engine Fuel & Filter – Clean/Replace Work Card 7751, dated 5/28/2008Item 44 · .PDF · 1.4 MBMaintenance Records 11 - Attachment 15 Right Engine Fuel & Filter – Clean/Replace Work Card 7752, dated 5/28/2008Item 45 · .PDF · 1.2 MBMaintenance Records 11 - Attachment 16 Computer print out for return to service for airplane N454AAItem 46 · .PDF · 625 KBCockpit Voice Recorder 12 - Factual Report of Group ChairmanItem 47 · .PDF · 1.2 MBMaterials Laboratory 15 - Factual Report 08-049Item 48 · .PDF · 3.1 MBMaterials Laboratory 15 - Factual Report 08-048 Salt LakeItem 49 · .PDF · 2.0 MBMaterials Laboratory 15 - Factual Report 08-098 AA 4XT valvesItem 50 · .PDF · 1.3 MBMaterials Laboratory 15 - Attachment 1 to 08-098 Trace Laboratory ReportItem 51 · .PDF · 547 KBMaterials Laboratory 15 - Fuel Fitting Test FactualItem 52 · .PDF · 1.3 MBSystems 9 - Factual Report of Group Chairman, Addendum 1Item 53 · .PDF · 63 KBSurvival Factors: Errata to Factual Report dated May 30, 2008Item 54 · .PDF · 15 KBMaterials Laboratory 15 - Factual Report 08-049 STL Rev1Item 55 · .PDF · 3.1 MBSystems 9 - Errata to Factual Report of Group Chairman dated May 21, 2008Item 56 · .PDF · 17 KBMaterials Laboratory 15 - Factual Report 08-048 SLC Rev1Item 57 · .PDF · 2.0 MBAmerican Airlines Submission for AA1400 accident investigationItem 58 · .PDF · 114 KBP & W letter submission on AA1400 accident investigationItem 59 · .PDF · 24 KBAPA Submission on AA1400 investigationItem 60 · .PDF · 20.0 MB
All 63 files on NTSB’s docket

FAA reports on this event · 1

The FAA’s own accident and incident reports, matched to the aircraft by N-number and date.

Other investigations on N454AA · 1

Matched to the same aircraft by N-number and date.