Speaking of Engine Fires and Delayed returns

Minuteman

Minuteman

I HAVE STRONG OPINIONS ABOUT AUTOMOTIVE LIGHTING!
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 [eight?] 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. A synopsis of the Board's report, including the probable cause, conclusions, and recommendations, is available on the NTSB's website, at http://ntsb.gov/events/Boardmeeting.htm. The Board's full report will be available on the website in several weeks.
Click to expand...

This sounds like something they would throw at a crew in a sim. :eek:
 
So engine fire, followed by a shutdown, followed by a failure of the nose gear to come down, followed by a single engine go around, followed by finally getting down and getting the folks off the airplane?

Isn't there a point at which you just say, "If this happens to you, good luck?"

I mean I hate that theory to a certain point, but there's only so much you can train for eh?

An engine fire isn't a HUGE issue once it's put out as far as I see things, and even if it's not put out? The engine falls off the aircraft. Problem solved.

I guess the question would be, if you had the fire put out, would you do the single engine missed? What if the fire hadn't been out?
 
Yeah what did they do so horribly wrong that resulted in the safe landing and evac of all those people? After all that went wrong???
 
Jeesh. I don't think I'll ever be buying rounds for the NTSB guys at the bar. They'd probably just bitch the beer was too cold anyway.
 
Then they would create a list of recommendations to prevent it from getting too cold in the future.
 
I find it incredulous that individuals who don't fly the line come to such conclusions. It seems that the NTSB hires plenty of academics (engineers, metallurgists, psychologists), but few who have substantial line experience.
 
The adage 'if it isn't broke, don't fix it' is really a complete crock. Fine tuning what we do every day is what makes us grow. Just because no one had any injuries doesn't mean things couldn't have gone tremendously worse and all they are doing is making sure things work out even smoother. A lesser crew might not have made it back if a similar situation happens again. OR what if one more problem is thrown into the mix? Maybe they wouldn't have been so lucky with current procedures...

My .00 cents(maybe sense?)
 
Any of you guys read the CVR transcript? If not, what's your basis for assuming the NTSB finding is wrong? Just because they survived doesn't mean that they couldn't have done anything better.
 
The brief says
  1. The pilots failed to properly allocate tasks, including checklist execution and radio communications, and they did not effectively manage their workload, which adversely affected their ability to conduct essential cockpit tasks, such as completing appropriate checklists.
  2. No preexisting indicators in the pilots’ training or performance histories were found that could explain their poor performance during the accident flight.
  3. The pilots’ interruption of the emergency Engine Fire/Damage/Separation checklist at a critical point prolonged the fire and led to additional problems, including the loss of hydraulic pressure, which caused the nose landing gear to fail to extend.
Click to expand...
There was another incident recently where a 757 crew failed to complete the checklist after getting a abmormal with the electrical sys. The crew continued and the battery failed and other buses then began dropping off line. The crew diverted to ORD, lost even more sys on final and departed the runway after landing.

Note: in the 2002 edition of the Flight Safety Foundation publication, listed at the number 3 position for highly significant problems was "crew failure to follow SOPs and slightly farther down the list, failure in decision making.

So, the question is not that the crew may not have followed checklist or SOPs or failed to properly assign tasks and manage task loading but WHY?

At any rate, although it ended well, seemingly not a stellar performance by the crew. More facts warranted...
 
Minnesota_Flyer said:
Any of you guys read the CVR transcript? If not, what's your basis for assuming the NTSB finding is wrong? Just because they survived doesn't mean that they couldn't have done anything better.
Click to expand...

Because I don't think I've ever been trained on such an outlandish situation. If I were going to give somebody emergency upon emergency in a sim I probably wouldn't be trying to see how they'd handle the situation and train on it, I'd most likely be trying to kill them.
 
jtrain609 said:
Because I don't think I've ever been trained on such an outlandish situation. If I were going to give somebody emergency upon emergency in a sim I probably wouldn't be trying to see how they'd handle the situation and train on it, I'd most likely be trying to kill them.
Click to expand...

although most training situations are single failure events, that does not mean the real world restricts itself to such pristine emergencies. For example, SwissAir 111 began with a faulty IFE and went to a smoke/fire situation that then went to a electrical system problem and then other sys failures.

.
http://aviation-safety.net/database/record.php?id=19980902-0
 
Very true, but where do you draw the line? There's only so much time you're given in a part 121 training program, to say nothing of the short amount of time you're given for RPC's. How much time can realistically be spent on emergencies that are unlikely to happen? It would seem that it would make sense to spend your time practicing an emergency that might actually happen, like flying a VOR approach.
 
jtrain609 said:
Very true, but where do you draw the line? There's only so much time you're given in a part 121 training program, to say nothing of the short amount of time you're given for RPC's. How much time can realistically be spent on emergencies that are unlikely to happen? It would seem that it would make sense to spend your time practicing an emergency that might actually happen, like flying a VOR approach.
Click to expand...

I misunderstood. I thought you were arguing that such training was worth physical confrontation.

As a former check airman, your point about time is also valid. 10lbs in a 5lb sock and always not enough time if anything is less than 'standard'.

VOR approach... now remind me.. what is that? :D

(FWIW, we were unable to get all departments into flying constant angle non-precisions before I retired although the data showed that 1) rounding UP the MDA to the next 100ft 2) CANPAs actually increased the rate of success 3) dive and drives more often resulted in unstablized approaches. We did succeed in getting policy so that all NPAs had to be flown w/ the autopilot. It was resisted but again, feedback showed an increased rate of success and reduced workload using the autopilot for NPAs. ILS? Hand fly it to 200 1/2 if you wanted but NPAs? Autopilot. Cat II/IIIA/B? Autopilot. )
 
You must log in or register to reply here.
Back
Top