St. Louis, Missouri
September 28, 2007
NTSB Number: AAR-09-03
NTIS Number: PB2009-910403
PDF Document
On September 28, 2007, about 1313 central daylight time, American Airlines flight 1400, a McDonnell Douglas DC-9-82, N454AA, experienced an in-flight 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 from the fire. The scheduled passenger flight was operating under the provisions of 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 National Transportation Safety Board determines that the probable cause of this accident was 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 (CASS) program.
The safety issues discussed in this report relate to the following: characteristics of the "Air Turbine Starter Valve (ATSV) Open" light; emergency task allocation guidance; guidance and training on the interrelationship between pneumatic crossfeed valves and engine fire handles; multiple simultaneous emergencies training; guidance on evacuation preparation on the ground; guidance and training on communications between flight and cabin crews during emergency and unusual situations; ATSV-air filter replacement intervals; and American Airlines' CASS. Safety recommendations concerning these issues are addressed to the Federal Aviation Administration and American Airlines.
