N80057
Airbus Industrie A-300B4-605R
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.
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 total of 9,500 hours of flying time, including 408 hours as an A300 first officer at AA. He had flown 3 hours, 45 hours, and 143 hours in the past 24 hours, 30 days, and 90 days, respectively. The first officer received his last checkride on September 10, 1997, when he initially qualified as an A300 first officer. His most recent FAA first-class medical certificate was issued on March 23, 1998, with no limitations. FAA records showed no enforcement actions, accidents, or incidents. See the Operations Group Chairman's Factual Report for additional information about the captain and first officer. See the Survival Factors Group Chairman's Factual Report for additional information about the seven revenue flight attendants and two nonrevenue flight attendants riding on the flight. AIRCRAFT INFORMATION N80057, an Airbus Industrie A-300B4-605R, serial number (S/N) 465, was manufactured in 1988. The airplane was registered to GEAE and operated by AA. At the time of the incident, the airplane had accumulated 27,845 total flight hours. The airplane was last inspected on May 28, 1998, 326 flight hours before the incident. The No. 1 engine was a GEAE CF6-80C2A5 turbofan, S/N 695250. The engine was last overhauled at Motoren-und Turbinen-Union (MTU), Hannover, Germany, from September to November 1995. The most recent repair of the engine occurred at the AA Maintenance and Engineering Center in Tulsa, Oklahoma, in September 1997, to replace several high-pressure turbine stage two blades and the main fuel pump. The engine had accumulated 1,806 flight hours and 727 cycles since repair; 5,484 flight hours and 2,178 cycles since overhaul; and 22,239 flight hours and 8,914 cycles since new, at the time of the incident. Examination of the engine revealed that the accessory gearbox adapter bolt inserts had backed out, allowing fuel lines (cross-over tubes) to unseat from the adapter. This allowed pressurized fuel to spray onto hot engine parts and ignite, resulting in the nacelle fire. On September 26, 1995, the adaptor had been reworked per GEAE Service Bulletin (SB) 72-743, which called for the installation of new adapter inserts to permit higher and more consistent bolt torque that would improve the clamping interface and eliminate fuel leaks from the adapter cross-over tube interface. The replacement insert specified in SB 72-743 was much smaller than the hole, and use of this insert would have allowed it to slide completely through the hole. MTU reworked the incident adapter to the SB; however, MTU did not use the insert specified in the SB. Instead, MTU installed an alternate insert using the GEAE Standard Practices Manual as a reference. However, the installed inserts were also too small for the adapter hole; consequently, the insert threads did not have the proper engagement with the housing, which permitted the fuel lines to unseat from the adapter. (The error in the SB was subsequently corrected by GEAE.) METEOROLOGICAL INFORMATION The Luis Munoz Marin International Airport surface weather observation taken at 0954 showed clouds were scattered at 3,700 feet above ground level, visibility 10 statute miles, winds from 70 degrees at 13 knots with gusts to 20 knots, temperature 84 degrees F, dewpoint temperature 79 degrees F, altimeter setting 30.08 inches Hg. AIDS TO NAVIGATION There were no reported problems with aids to navigation. COMMUNICATIONS There were no reported problems with communications between the flight crewmembers of AA flight 574 and ATC personnel. AIRPORT INFORMATION Luis Munoz Marin International Airport is located about 3 miles southeast of the city of San Juan, Puerto Rico. The airport is owned and operated by the Port Authority, Commonwealth of Puerto Rico. It has an FAA-approved emergency plan and is certified as an Aircraft Rescue and Firefighting (ARFF) Index D airport under 14 CFR Part 139. It has an elevation of 10 feet above mean sea level. The airport has two runways, one grooved concrete and the other asphalt, with precision instrument markings. Runway 8-26, used by flight 574, is asphalt, 10,002 feet long, and 200 feet wide. ARFF personnel and equipment were stationed adjacent to runway 8 as flight 574 landed. As the airplane came to a stop, ARFF personnel immediately began firefighting efforts on the No. 1 engine; the fire was extinguished in 45 seconds. FLIGHT RECORDERS The incident airplane was equipped with a digital flight data recorder Sundstrand Model UFDR, S/N 9783, which recorded about 200 parameters. The recorder was read out at the Safety Board's Vehicle Recorder Laboratory in Washington, D.C. The incident airplane was equipped with a Fairchild model A-100A CVR, S/N 53281. The recorder was read out at the Safety Board's Vehicle Recorder Laboratory in Washington, D.C. The CVR recording consisted of four channels of fair quality audio information, which included flight crew communications, ATC transmissions to and from the airplane, PA, and interphone transmissions. Timing on the CVR recording was established using an ATC transcript supplied by the FAA. The recording started as the flight crew was preparing for departure at the gate. The transcript of the CVR recording started at 10:04:32 as the flight crew was commencing the takeoff for departure to Miami and continued uninterrupted until 10:25:25, when electrical power was removed from the CVR. MEDICAL AND PATHOLOGICAL INFORMATION Twenty-eight passengers reported receiving minor injuries during the evacuation and were treated by fire department personnel at the airport or transported to hospitals for treatment. FIRE A fire occurred in the No. 1 engine. SURVIVAL ASPECTS The incident was survivable. There were no serious or fatal injuries sustained by the occupants of the incident airplane or by persons on the ground. During the emergency evacuation, door 3R failed to open completely and the slide failed to activate. An FAA inspector stated that "after entering the plane at the gate, he went to door 3R and rested his hand on the fairing that covers the door hinge." The slide "fell immediately to the ground" and "made a hissing noise." He described the door as being "90 percent open" and the girt bar was disengaged. Examination of door 3R revealed no visible damage to the door structure, packboard, lacing cover, or decorative cover. The girt bar floor fittings showed no signs of damage and appeared to have been recently greased. The door was cycled without slide weight but with the packboard and yellow lacing cover attached. During the postincident examination, the door operated normally. The 3R slide (part number (P/N) 31021-107, S/N 0348) was manufactured by Air Cruisers Company in January 1992 and last overhauled in October 1997. Examination of the slide showed no tears, cuts, or abnormalities to the exposed area of the inflatable. The gauge adapter was fractured at the threaded section of the neck of the valve assembly. There was zero pressure in the cylinder and no damage to the grommets. During examination, it was noted that the outboard portion of the girt was located on the inboard portion of the girt bar. The clip girt retainer was installed properly with respect to the slide girt, but when installed in the airplane it would have been located on the outboard edge of the girt bar, rather than on the inboard edge. The inflation cable was disconnected at the quick disconnect. Four slide pack release pins showed no obvious signs of damage. Further examination of the forward and aft "parachute pin assemblies" for damage to the cable and webbing assemblies revealed that the aft cable assembly appeared to be pinched and twisted. During the evacuation, door 1L was partially opened in an attempt to determine if it could be used for passenger egress. Because of the fire trucks blocking it, the door was not used; however, after the girt bar was disengaged, the slide packet fell from the door and inflated on the ground. On July 13, 1998, the actuator bottle unit (P/N 7015600002, S/N 46478) at door 1L was still fully charged and its gauge was reading 1,950 pounds per square inch (psi). The actuator unit from door 1L was removed from the airplane and examined at Barfield Incorporated in Miami, Florida, on July 23, 1998. The operating lever
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.
Source: NTSB Aviation Accident Database
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