St. Louis, MO, USA
N454AA
MCDONNELL DOUGLAS DC-9-82 (MD-82)
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.
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 stated, “we’ve got no left engine; we’ve got no right hydraulic pressure…we don’t have any hydraulics on left side.” Shortly thereafter, the STL ATCT controller confirmed that the nose landing gear had extended. The off duty company pilot used the public address system to brief the passengers on the situation. He then contacted the flight attendants on the interphone and stated, “not going to do ground evacuation…but be ready.” The flight was cleared to land at 1329:20, and the captain landed the airplane successfully about 1332. After the airplane stopped on the runway, ARFF personnel applied fire extinguishing agent to the left engine. Initially, the airplane was going to be towed to the airplane terminal. However, subsequent events led ARFF personnel to call for the passengers to be deplaned. The passengers were deplaned without incident about 1410.
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.
Source: NTSB Aviation Accident Database
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