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Mechanics, crew faulted in MD-82 engine fire

Singlecoil

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WASHINGTON (AP) -- American Airlines failed to catch repeated errors by mechanics before a September 2007 flight that made an emergency landing after one of its engines caught fire during departure.
The 143 people onboard weren't injured, but the incident could have become catastrophic because of additional mistakes by the flight crew, members of the National Transportation Safety Board said Tuesday.
The four-member board recommended changes in pilot training programs to take into account simultaneous emergencies.
The findings come as American faces heightened scrutiny by the Federal Aviation Administration.
The agency recently assigned a special team of 17 inspectors to examine American's aircraft maintenance and other operations. The special audit is expected to take about three months.
The NTSB's hearing on Tuesday was held to examine the Sept. 28, 2007 incident in which American Flight 1400's left engine caught fire during a departure climb from Lambert-St. Louis International Airport.
The MD-82, a mid-sized airliner, returned to the airport, but fire had damaged the aircraft's hydraulic system so that the plane's rudder wasn't functioning and the nose landing gear failed to extend during an initial landing attempt. A second attempt was successful.
While there were no injuries, the plane sustained substantial damage.
American spokesman Tim Wagner said the airline is changing training procedures for mechanics and pilots as a result of the incident, and hiring more auditors to review maintenance work.
NTSB's issues "were with our personnel not following our procedures rather than any problem with our procedures," he said.
Investigators said the engine had had repeated trouble starting beginning 10 days before the incident. Maintenance crews replaced a starter valve six times during that period. On the day of the incident, the engine again failed to start when the plane was at the gate and had to be started manually a second time before Flight 1400 took off.
It turned out mechanics had failed to properly maintain a metal air filter, which disintegrated, investigators said. The destruction of the filter led to a series of other mechanical problems, including a bent pin, which helped caused the engine fire.
During the fire, the flight crew made several mistakes that acerbated the problem and could have led to a more serious accident, investigators said.
The pilot interrupted his emergency checklist to inform passengers of the trouble, which delayed his shut-off of fuel to the fire and allowed the fire to burn longer, investigators said. That led to the damage to the hydraulic system, they said.
"We probably wouldn't be here talking if he had done that checklist in a timely manner," investigator Dave Tew said.
The co-pilot was engaged in trying to wrestle the cockpit door closed after the fire partially shutdown the aircraft's electrical system, which released the automatic door lock, they said.
"It seems to me it was a series of people taking shortcuts that accumulated on this particular day into what could have been much more catastrophic," said safety board member Kitty Higgins.
Last August, the FAA asked American to pay a $7.1 million civil penalty -- one of the largest ever assessed against an airline -- for continuing to fly two jets after an FAA inspector and American's own mechanics found problems with their autopilot systems.
American, a unit of Fort Worth-based AMR Corp., operates the world's largest fleet of MD-80 series planes, with 275 of them. When oil prices spiked last year, American stepped up plans to replace them with more fuel-efficient jets, but that will take years.
As they age, the MD-80s are facing more maintenance issues. Last July, the FAA ordered airlines to inspect certain MD-80 models -- including most of American's -- for cracks on overwing frames. Last April, American grounded its entire MD-80 fleet to repack the electrical wiring, causing the cancellation of more than 3,000 flights.
Associated Press Writer David Koenig in Dallas contributed to this report.
 

regionaltard

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I'm astonished by the training emphasis placed on the cockpit keeping the passangers "in the loop" during abnormal and emergency operations. There ought to be a separate checklist for it, and the first memory item should be:

Are we all caught up?
 

densoo

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During the fire, the flight crew made several mistakes that acerbated the problem and could have led to a more serious accident, investigators said.
"acerbated"? I think it's "exacerbated."

ac·er·bate
tr.v. ac·er·bat·ed, ac·er·bat·ing, ac·er·bates To vex or annoy.

ex·ac·er·bate
tr.v. ex·ac·er·bat·ed, ex·ac·er·bat·ing, ex·ac·er·bates To increase the severity.

... not that there's anything wrong with that.

Is there nothing they won't find a way of blaming the pilot for? Improper mx dozens of times and when it breaks it's the pilots' fault because they happened to be flying it at the time.
 
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ImbracableCrunk

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"acerbated"? I think it's "exacerbated", not that there's anything wrong with that.

ac·er·bate
tr.v. ac·er·bat·ed, ac·er·bat·ing, ac·er·bates To vex or annoy.

ex·ac·er·bate
tr.v. ex·ac·er·bat·ed, ex·ac·er·bat·ing, ex·ac·er·bates To increase the severity,

Aren't you glad no one buys newspapers anymore? No one to fact check, spell check, or double-check. It's gonna be a bunch of internet newsies and a few screaming heads on TV.
 

densoo

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The pilot interrupted his emergency checklist to inform passengers of the trouble, which delayed his shut-off of fuel to the fire and allowed the fire to burn longer, investigators said. That led to the damage to the hydraulic system, they said.

A - Aircraft--fly it
B - Bold face/immediate action items--do them
C - Checklist/QRH--read it
D - Data, landing distances, inflight min control speed, whatever--compute it
E - Emergency -- declare one

F, G, H, I, J, K, L, M, N, O,

P - P.A.--make one
 

Rez O. Lewshun

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************************************************************
NTSB PRESS RELEASE
************************************************************
National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: April 7, 2009
SB-09-14
************************************************************
CAUSE OF MD-80 ENGINE FIRE LINKED TO MAINTENANCE AND FLAWED
SAFETY MANAGEMENT SYSTEM, NTSB SAYS
************************************************************
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.
 

Colonel Savage

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"The pilot interrupted his emergency checklist to inform passengers of the trouble, which delayed his shut-off of fuel to the fire and allowed the fire to burn longer, investigators said..."

So he pulled the throttle back, and while waiting the 60 seconds or so to see if the fire warning went out (bleed air leak test) before shutting the fuel off, he decided to give the pax the "we got a little problem and heading back to NYC..."

So they dinged him...
 

densoo

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************************************************************
NTSB PRESS RELEASE
************************************************************
2) ensure that pilots are trained to refrain from
interrupting the completion of emergency checklists with
nonessential tasks;

No kidding. And not just in emergencies. There seems to be a pendulum swing away from keeping it simple. Normal Procedures are now filled with non-essential tasks that lure pilots away from their primary job of flying the plane. Are they surprised that what is practiced day-to-day is what is done in an emergency? And the FAA bears some responsibility for this when they assign POIs to the airline who feel it is their job to drive the focus to the non-essential. When a debriefing includes "you shouldn't turn on the wheelwell light as a reminder to yourself that tower has cleared you to land because that's not what it is there for," then the evaluator has lost all sense of proportion about what pilots are doing.

I know. Let's make a horn that tells pilots that they haven't configured the plane properly for takeoff. Aborted takeoff problem solved. What? A plane crashed killing all on board because that same horn was telling them the cabin was not pressurizing on climbout but the crew spent the final three minutes of their lives looking for a takeoff configuration problem instead of a pressurization problem? Who woulda thought?
 
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ThisistheDream

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The plane landed and noone was hurt.!!!!!!! That in itself deserves 1000 thanks and a job well done phone call for THE FLIGHT CREW!!!! The monday morning quaterbacks, second guessing needs to stop when analyzing what the pilots did!!! The fact that they took thier time and landed that aircraft with no injuries is what the overall goal is when your dealt with a emergency like that!!!
 

Propsync

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The plane landed and noone was hurt.!!!!!!! That in itself deserves 1000 thanks and a job well done phone call for THE FLIGHT CREW!!!! The monday morning quaterbacks, second guessing needs to stop when analyzing what the pilots did!!! The fact that they took thier time and landed that aircraft with no injuries is what the overall goal is when your dealt with a emergency like that!!!

I think you missed the point. If nothing is done, maybe the next time a flightdeck crewmember decides to do a pa at the wrong time....

One of the few things I disagreed with in training.

1. Use CRM and established procedures to try to land aircraft safely.
2. Let PAX know that number 1 was accomplished. I don't get where making a PA to x number of pax without controls will ever help you.
 

Minimaniac

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I am not sure I agree with multiple emergency training, as listed in the recommendations. First, there are so many possible combinations of multiple emergencies that any scenario really loses relevance. Second, we all receive multiple emergencies during training, but not during the actual pass/fail portion of a checkride. Leave the grading criteria as is. There is enough decision making to be done during a single emergency that a pilot's skills can be properly evaluated.

It is difficult to even come up with a list of priorities during a multiple emergency situation that would be useful a majority of the time. Aviate-Navigate-Communicate is about as thorough as one can teach it. You have a loss of thrust on one engine and a loss of a hydraulic system. Which do you deal with first? I would say it depends on which engine, which hydraulic system, and phase of flight. Training will never cover all the possible combinations of the above for just those two simultaneous emergencies, let alone every other likely combination of emergencies.

This crew got the job done. Talking on the PA during a checklist is a bad idea on the surface, but as others pointed it may have occurred during a checklist-mandated pause. Would the NTSB fault Sully for telling everyone to brace for impact in the middle of his checklists? His PA probably prevented dozens of injuries or even deaths. But, the American flight ended less dramatically, so I guess we can blame the crew. To me this is like blaming Sully and Co for not properly dividing their attention between looking inside and outside the cockpit. Maybe if they were utilizing see and avoid...blah blah blah.

Good job, American pilots. Sorry that again you have to shoulder the blame for a situation caused by poor maintenance.
 

BeCareful!

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with an engine fire at V1, following procedure, it might be 2-3 minutes before you do anything at all with the burning engine while climbing to 1000ft....TL still up and everything. Not that anyone make a PA during this phase, but on a hot day in a full 737 you'd certainly have the time to and it wouldn't change the speed at which you handled the fire.

Lame NTSB. Still, Rez is probably right, it's the APA's fault for ceasing CASS :)
 

AA717driver

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Just finished recurrent. They emphasized making limited PA's during QRH procedures.

AA's culture is changing--slowly. In the past, the cockpit was one big briefing session and PA-fest from pushback to takeoff.

At least the moved the brief to the "Before Starting Engines" checklist.

The CA STILL makes the announcements to FA's while taxiing.

It's a process...

In this case, the NTSB could have made the same point without listing the pilots as a major fault in the incident. I guess AMR didn't want the mechs to take ALL the heat. :rolleyes:

TC
 

aa73

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J

The CA STILL makes the announcements to FA's while taxiing.

He is referring to the mandated PA announcement, "Flight attendants, prepare for takeoff".... a PA that is made by the F/O at EVERY other airline in the world.

I've tried and tried to have this PA changed to the F/O by submitting it to the Flight Dept but it continuously gets shot down. Their reasoning is that the F/O already has too much to do on the Taxi and Before TO checklists while the CA is just sitting there taxiing (hello, that's his job and should be his ONLY job - not talking on the PA!).

Now, contrast that to the ridiculous PA F/Os have to make while arriving at the gate - a time when we should be outside making sure we are not hitting anything. "L&G please remain seated until the CA turns off the seat belt sign, FAs prepare for arrival and crosscheck." A PA that is made by the FAs at every other airline in the world when the seat belt sign turns off.

I don't understand AA's PA philosophy??

That said, outstanding job to the AA1400 crew. They dealt with multiple emergencies and brought it back safely. The NTSB can nitpick and Monday morning QB all they want... nobody is going to do it perfectly. If you have a minute or to during a checklist, WHY NOT inform the pax real quick. Kudos.
 
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Patriot328

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The CA STILL makes the announcements to FA's while taxiing.



TC

Is that because the FO is buring 6 feet deep in that mechanical checklist (if y'all still have them)?

One thing I gotta say about CAL, we don't do sh*t while taxiing except for a 4 item before takeoff check; and the FO sits the FAs down.
 

aa73

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Is that because the FO is buring 6 feet deep in that mechanical checklist (if y'all still have them)?

One thing I gotta say about CAL, we don't do sh*t while taxiing except for a 4 item before takeoff check; and the FO sits the FAs down.

Yes, we still have the mechanical list. Actually the mechanical is a great idea that's being incorporated today in "glass checklists" like on the 777. The problem with ours is that it's too dang long! 10 items on the before T/O at last count on the 75/76.
 

AA717driver

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Is that because the FO is buring 6 feet deep in that mechanical checklist (if y'all still have them)?

One thing I gotta say about CAL, we don't do sh*t while taxiing except for a 4 item before takeoff check; and the FO sits the FAs down.

AA73 is right, it could be shorter. But the ability to skip down the list and get the easy stuff out of the way is good.

It's close to being a heads up checklist.

All in all, it's a plus, IMO.

TC
 

Flybywire44

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He probably delayed the checklist by 20 seconds max. Maybe him telling the passengers was a way of mentally collecting himself... so be it. Engines are made to withstand burning for a brief period... I love how they did not mention how many seconds he delayed the checklist by. Had they done that it would have been pointless to mention the delay!

Someone likes demonizing pilots. Maybe the investigator's wife left him one.
 

Patriot328

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Yes, we still have the mechanical list. Actually the mechanical is a great idea that's being incorporated today in "glass checklists" like on the 777. The problem with ours is that it's too dang long! 10 items on the before T/O at last count on the 75/76.


What on earth is on it (that can't be done before taxiing?)
 
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