NTSB Criticizes American Air for 2007 Incident

Air Safety Week, May 25, 2009

The National Transportation Safety Board (NTSB) is urging American Airlines to correct numerous deficiencies revealed in the probe of a 2007 emergency landing by a crippled and fire-damaged jetliner in St. Louis.

The Safety Board also urges the Federal Aviation Administration to reassess pilot training for situations involving engine failures combined with other types of emergencies.

The recommendations stem from a September 28, 2007 incident in which a McDonnell Douglas MD-82 (N454NN) jetliner operated by American suffered an in- flight fire in one of two engines shortly after takeoff from Lambert-St. Louis International Airport (STL).

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 two flight deck crewmembers, three flight attendants, and 138 passengers deplaned on the runway. No injuries were reported, but the airplane sustained substantial damage from the fire.

The NTSB determined that the probable cause of the 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 (ATSV), 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."

Aside from the ATSV problem followed by indications of an engine fire. the pilots also encountered several other abnormal events, including electrical and hydraulic system anomalies and the nose landing gear's failure to extend. The investigation revealed that the flight crew did not perform several of the appropriate checklists, and they interrupted an emergency fire-related checklist.

The NTSB concluded that "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. The NTSB further concludes that no preexisting indicators in the pilots' training or performance histories were found that could explain their poor performance during the accident flight."

The NTSB recommends that "the FAA require principal operations inspectors to review their operators' pilot guidance and training on task allocation and workload management during emergency situations to verify that they state that, to the extent practicable, the pilot running the checklists should not engage in nonessential operational tasks, such as radio communications."

On another matter, CVR evidence and post-accident statements indicated that the flight attendants did not detect smoke or fumes in flight. However, during the flight, the two flight attendants seated in the aft cabin did discuss hearing some popping noises that they thought could be associated with the left engine, but they did not convey this information to the cockpit or the lead flight attendant. At the time that the noises were heard, the pilots were shutting down the left engine and using the fire-extinguishing agent, and, therefore, it is unlikely that this information would have changed the outcome because the information was consistent with the known situation.

"Regardless, the NTSB is concerned that the information was not conveyed to the cockpit, as required by proper crew resource management (CRM) procedures and company guidance that all crewmembers provide pertinent information to the captain to help in decision-making," the Safety Board said.

"Further, after landing, the pilots did not actively seek information from the flight attendants because they believed that the flight attendants would pass any significant information to them. However, long after the fuel spill, during the debriefing on the ground, a flight attendant stated that she had smelled fuel earlier, but she did not pass this information to the cockpit when it happened, which was, again, inconsistent with the pilots' expectations and with company guidance and proper CRM," the NTSB noted.

The NTSB has had longstanding concerns about the need for effective communications between pilots and flight attendants and has issued numerous safety recommendations and reports on this subject.

"The issue of communication has also been examined by the research community and by industry training. However, this accident shows that this issue needs to be addressed further," the Safety Board believes.

The NTSB concluded that, during the emergency situation, the flight attendants did not relay potentially pertinent information to the captain in accordance with company guidance and training.

"The NTSB recommends that the FAA revise AC 120-48 to update guidance and training provided to flight and cabin crews regarding communications during emergency and unusual situations to reflect current industry knowledge based on research and lessons learned from relevant accidents and incidents over the last 20 years," the Safety Board said.