- Date
- July 9, 1998, 10:07 local (14:07 UTC)
- Place
- San Juan, PR
- Injuries
- 28 minor, 224 uninjured
- Damage
- Minor damage
- Phase of flight
- Enroute
- Aircraft
- N80057Airbus Industrie A-300B4-605R
- Weather
- Visual (VMC) · Day
- Status
- Completed · report November 16, 1999
- Report
- Approved by Office Director
- Safety recommendations
- Yes
- FAA report
- 19980709037259I
- Case key
- 38412
From the NTSB’s public API. By law, NTSB reports can’t be used as evidence in lawsuits over the incident.
On this page
Probable cause
The NTSB’s determination of the probable cause, and any contributing factors.
An in-flight engine fire resulting from (1) the failure of the engine overhaul facility to install, and the failure of American Airlines to ensure installation of, the proper adapter bolt inserts to preclude fuel leakage and the failure of the engine overhaul facility to notify the aircraft operator and the engine manufacturer, and request correction, of an error in Service Bulletin (SB) 72-743; and (2) and the failure of General Electric Aircraft Engines to specify the proper adapter bolt insert and to correct SB 72-743 after notification of the error. Contributing to the severity of the incident were (1) the flight crew's failure immediately to complete the in-flight engine fire procedures and (2) the failure of Airbus Industrie and American Airlines to provide all necessary information in the in-flight engine fire procedures.
Analysis
Shortly after takeoff, as the flight climbed through 3,100 feet, the No. 1 engine fire warning activated. About 20 seconds later, the captain, who was the pilot flying, moved the No. 1 throttle to idle and asked the first officer to declare an emergency with air traffic control. About 47 seconds after the first officer identified the No. 1 engine fire warning, the captain asked the first officer to perform the engine fire emergency procedures checklist. The engine fire warning system deactivated because of fire damage to one of the fire loops, about 88 seconds after the fire warning activated and 2 seconds before the first officer moved the No. 1 fuel lever to the off position, shutting down the No. 1 engine. The flight crew did not notice the warning that the No. 1 fire loop system was inoperative. The engine fire warning system uses two loops. If one loop should no longer sense a fire or become inoperative because of fire damage, the engine fire warning will deactivate and a fire loop warning will be displayed to the flight crew. The flight crew must deactivate the faulty loop to regain the engine fire warning. The crew elected to stop the procedure after shutting down the No.1 engine because the fire light went out, and therefore did not activate the No.1 fire handle. Pressurized fuel continued to be supplied to the engine and feed the engine fire. The flight crew turned back to the departure airport. At 2,000 feet, about 3 minutes from landing, a flight attendant reported that a mechanic in the back had stated that the No. 1 engine was still smoking or on fire. The flight crew did not take any action and landed. About 1 minute after stopping, the captain ordered an emergency evacuation of the airplane, with instructions not to use the left overwing exits. About 1 minute 55 seconds after landing, the flight crew pulled the engine and auxiliary power unit fire handles and discharged the fire bottles into the No. 1 engine. In 1995, Airbus changed the engine fire procedure to allow for discontinuing the fire procedure and keeping an engine running at idle after an engine fire warning once the fire warning has gone out and after the throttle has been moved to idle. This change was made because of the high number of bleed air leak activated fire warnings. Postincident examination of the No. 1 engine showed that all the accessory gearbox idler adapter attachment bolt inserts had backed out, allowing fuel lines to unseat and spray pressurized fuel onto hot engine parts and ignite. On September 26, 1995, the accessory gear box idler adapter had been reworked per General Electric Aircraft Engine Service Bulletin 72-743 during engine overhaul at a vendor's facility. Smaller-than-required adapter bolt inserts had been installed.
Factual narrative
The factual narrative1,354 words
History of flight
On July 9, 1998, about 1007 Atlantic standard time, an Airbus Industrie A300B4-605R, N80057, registered to General Electric Aircraft Engines (GEAE) and operated by American Airlines, Inc. (AA), as flight 574, had a fire in the No. 1 engine shortly after takeoff from Luis Munoz Marin International Airport, San Juan, Puerto Rico. The airplane received minor damage. The captain, first officer, 7 flight attendants, and 215 passengers were not injured. Twenty-eight passengers reported receiving minor injuries during the postlanding emergency evacuation. The airplane, operated by AA as a scheduled passenger flight under the provisions of Title 14 Code of Federal Regulations (CFR) Part 121, was destined for Miami, Florida. Visual meteorological conditions prevailed at the time and an instrument flight rules flight plan had been filed.
During postincident interviews, the first officer stated that nothing appeared unusual about the No. 1 engine during preflight inspection and that neither the airplane nor the ground showed evidence of leakage. The captain (the pilot flying) stated that the engine start and taxi out were normal. He stated that he engaged the autothrottles for takeoff and that the takeoff and climb were normal. About 4,000 feet, he reported hearing a thump and that he did not feel any vibration after hearing the "thump." About 4,500 feet, the No. 1 engine fire warning went off; he observed the fire light illuminated in the overhead fire handle as he was hand-flying the airplane with the autothrottles engaged. Almost immediately, the autothrottles were disengaged and he made a left turn towards San Juan. He told the first officer to call air traffic control (ATC) and to declare an emergency and get clearance to return and land at San Juan. They leveled at 5,000 feet. ATC said to turn left to 210 degrees and cleared them to descend to 3,000 feet. The captain stated that he had already put the left engine to idle and reduced the right throttle to idle.
About 47 seconds after the engine fire warning, the captain told the first officer to run the Electronic Centralized Airplane Monitoring (ECAM) checklist. The flight officer said that he then began to address the fire issue. He completed the checklist items down to the fuel lever OFF. About 88 seconds after the fire warning activated and 2 seconds before the first officer moved the No. 1 fuel lever to the OFF position, shutting down the No. 1 engine, he reached for the fire handle. The fire light was out, which he told the captain. The first officer stated that the operating manual states that you can stop the fire procedure if the fire light has gone out. He mentioned this to the captain and asked if he should continue with the ECAM checklist. They elected to stop the fire procedure before pulling the fire handle and returning to land. The first officer said that there was no procedure to check continuity of fire loops after a fire warning. The airplane's normal loop positions are both loop switches on and no faults; both loop switches were on. He did not recall getting a loop warning light after the fuel lever was moved to OFF. He stated that a warning went off, which he thought was a fuel filter clog light; a single chime also went off. According to the airplane's design, if the fire light goes out when the throttle is pulled back, the chime will cease.
The captain stated that about 1,000 feet, during the approach to land, the interphone rang and the first officer answered it. It was the purser and he informed the first officer that an AA mechanic was on board and possibly saw smoke and fire in the No. 1 engine. The captain stated that he told the first officer to tell ATC they might have a fire and to "standby the emergency evacuation checklist." While still airborne, the first officer told the tower that they might still have smoke in the engine.
The captain stated that he landed about 1,000 feet down runway 8 and stopped about a third of the way down, abeam to gate 19. As soon as the airplane stopped, he pulled the No. 1 fire handle and fired both bottles. He called the tower and asked if they saw smoke or fire. The tower confirmed smoke and fire. According to the cockpit voice recorder (CVR), the captain ordered an emergency evacuation 1:03 minutes after stopping on the runway. The captain stated that he started the ground evacuation checklist and that he announced on the public address (PA) system, "do not use the left overwing exits." After completing the checklist, he left the cockpit. A flight attendant told him that the airplane was empty. He stated that there were no restrictions to visibility in the airplane and he could see it was clear. He stated that he exited through the 1 right (1R) door, even though according to AA procedures his assigned emergency evacuation exit was door 4 right (4R), because the fire marshal wanted him off of the airplane.
The purser stated that during the evacuation he cracked door 1 left (1L) a little and saw that fire trucks blocked it. He elected not to use this exit. The remainder of the flight attendants on the left side of the airplane also did not open their doors. The flight attendants directed all of the passengers to the right side exits.
The flight attendant stationed at the 1R door stated that he activated the door for the evacuation, but it only went out about 1 foot and then stopped. He pulled the door back in and pushed it out again to unjam the evacuation slide from the door. The door then opened and the slide activated. The flight attendant stationed at the 2 right (2R) door stated that the door and slide activated normally. The flight attendant stationed at the 3 right (3R) door stated that when he activated the door, the door hung up on the evacuation slide and he could not get the door to open or the slide to activate. He blocked off the exit and redirected the passengers to other exits. The flight attendant stationed at door 4R stated that the door and slide activated normally.
Injuries to persons
Injuries Flight Crew Cabin Crew Passengers Other Total
Fatal 0 0 0 0 0
Serious 0 0 0 0 0
Minor 0 0 28 0 28
None 2 7 215 0 224
Total 2 7 243 0 252
Damage to airplane
The airplane received minor fire damage in the area of the No.1 engine and No. 1 pylon. The left wing and flap in the area of the No. 1 engine were also damaged. Examination of the airplane revealed that the fire damaged the No. 1 engine's fan cowls, thrust reverser, core cowls, engine core compartment external to the engine cases, and fire detection system. The airframe experienced heat damage that included wrinkling and blistering of the pylon and flap actuating fairing surfaces. There was no indication of an internal engine fire.
Other damage
No other damage resulted from this incident.
Personnel information
The captain, age 53, was hired by AA in May 1976. He holds an airline transport pilot (ATP) certificate with type ratings in the DC-9 and A310 and a flight engineer certificate. At the time of the incident, he had an estimated total of 17,100 hours of flying time, including 3,705 hours as a A300 captain at AA. He had flown 3 hours, 63 hours, and 130 hours in the past 24 hours, 30 days, and 90 days, respectively. The captain received his last checkride on February 14, 1998. His most recent Federal Aviation Administration (FAA) first-class medical certificate was issued on February 9, 1998, with limitations requiring him to possess corrective glasses for near vision. FAA records showed no enforcement actions, accidents, or incidents.
The first officer, age 41, was hired by AA in August 1987. He holds an ATP certificate with a type rating in the A310 and a flight engineer certificate. At the time of the incident, he had an estimated
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.
Aircraft
- Registration
- N80057
- Reported as
- Airbus Industrie A-300B4-605R (A300B4-605)
- Category
- Airplane
- Serial number
- 465
- Airframe hours
- 27,845
- Engine
- GE CF6-80C2A5, 61,500 lbs thrust, turbo fan
- Damage
- Minor damage
- Fire
- In-Flight
- Flight
- Part 121
- Operator
- American Airlines, Inc.
- Registered owner
- General Electric Co.
- Airworthiness certificate
- Standard, Transport
- Last inspection
- Continuous airworthiness · May 28, 1998 · 326 hours before
- Departed
- SJU
- Destination
- MIA · Miami, FL
- Flight plan
- IFR
- Airport
- SJU · Luiz Munoz Marin Int'L, runway 8, 10,002 × 200 ft, asphalt
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
As NTSB recorded them. NTSB leaves out names.
- Role
- Pilot
- Age
- 53
- Certificates
- Airline transport, Flight engineer
- Airplane ratings
- Single-engine land, Multi-engine land
- Instrument ratings
- Airplane
- Medical
- Class 1, Valid Medical--w/ waivers/lim
- Seat
- Left
- Flight hours
- 17,100 total · 3,705 in this make and model
Weather
- Conditions
- Visual (VMC) · Day
- Wind
- 70° at 13 knots, gusting 20
- Visibility
- 10 statute miles
- Lowest ceiling
- None
- Temperature
- 84 °F, dew point 79 °F
- Altimeter
- 30.00 inHg
- Observed at
- SJU, 2 nm away
Docket · 59
The files NTSB released with the investigation on February 15, 2000, on NTSB’s docket system: statements, records, photos and specialists’ reports.
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 N80057 · 2
Matched to the same aircraft by N-number and date.