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Safety Recommendation Details

Safety Recommendation A-09-021
Details
Synopsis: On September 28, 2007, about 1313 central daylight time, American Airlines flight 1400, a McDonnell Douglas DC-9-82 (MD-82),2 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.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Evaluate the history of uncommanded air turbine starter valve (ATSV)-Open events in the MD-80 fleet and the effectiveness of coupling the ATSV-Open light to the Master Caution system to determine whether all MD-80 airplanes need to be modified to couple the ATSV-Open light to the Master Caution system. Once the evaluation is completed, require any necessary modifications.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Action
Mode: Aviation
Location: St. Louis, MO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA07MA310
Accident Reports: In-Flight Left Engine Fire, American Airlines Flight 1400, McDonnell Douglas DC-9-82
Report #: AAR-09-03
Accident Date: 9/28/2007
Issue Date: 5/19/2009
Date Closed: 9/12/2011
Addressee(s) and Addressee Status: FAA (Closed - Acceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 9/12/2011
Response: Thank you for the description of the FAA’s review of ATSV problems reported by MD-80 operators for the period January 2007 to April 2009. The FAA’s review of the service history satisfies the first part of this recommendation. The review found only two actual ATSV-Open events since the issuance of airworthiness directive (AD) 98-09-19. Both of these events occurred on American Airlines flights that were discussed in the letter that transmitted this recommendation to the FAA. As a result of the events that had occurred on their flights, American Airlines revised its maintenance procedures to comply with Boeing’s maintenance procedures for servicing the ATSV filters, and no similar events have occurred since this revision. The FAA’s review of the service history also found that the number of false indications significantly outnumbered ATSV-Open events that led to starter failures; therefore, coupling the START VALVE annunciation to the master caution system would result in false indications that would far outnumber the original problems. The FAA concluded (1) that the AD had been successful in correcting identified design problems, and (2) that the previous two events on American Airlines had occurred due to improper maintenance that has now been corrected. For those reasons, the FAA does not believe that coupling the ATSV-Open light to the master caution system should be required, and the agency plans no further action. The FAA has completed the action recommended; therefore, Safety Recommendation A-09-21 is classified CLOSED—ACCEPTABLE ACTION.

From: FAA
To: NTSB
Date: 5/26/2011
Response: CC# 201100227: - From J. Randolph Babbitt, Administrator: A review of ATSV problems reported by MD-80 operators for the period January 2007 to April 2009 included 4 operators, over 500 airplanes, and an estimated 2.8 million flight hours. The findings were: • ATSV opening events leading to starter failure in flight: No events other than the two American Airlines events that are the subject of Safety Recommendations A-09-21 and A-09-28; • ATSV open indications in flight or not specified: Ten events in which there were no starter failure and no evidence the ATSV actually opened; and • ATSV open or valve indication problems on ground: 236 events. • American Airlines addressed the two in-flight events of uncommanded ATSV openings by revising their maintenance procedures to incorporate Boeing's published maintenance procedures for servicing the subject filters. Evaluation of the 10 in-flight and 236 on-ground ATSV open indication events revealed that the problem was due to a faulty position switch on the valve. Since the position switch is integral with the ATSV, the corrective action is to replace the faulty ATSV with a new or overhauled unit. Our review of service history data confirmed that since accomplishment of Airworthiness Directive (AD) 98-09-19 there have been two actual ATSV open events. The number of false indications to the crew significantly out numbers ATSV open events leading to starter failures. Coupling the START VALVE annunciation to the master caution system would result in additional conditions requiring an immediate crew response. Intermittent START VALVE OPEN annunciation could lead to repeated false MASTER CAUTION alerts, which could occur during times of high flight crew workload (for example, during takeoff). We are concerned this could cause the flight crew to miss higher priority indications and problems with other systems. Based on our review of recent service data, we believe past AD actions have been successful in correcting identified design problems. The two confirmed events, due to improper maintenance practices by the airline, have since been corrected with no additional occurrences. Based on this review, we consider that safe MD-80 operations will be maintained without adding further complexity to the MASTER CAUTION system and potential inadvertent consequences.

From: NTSB
To: FAA
Date: 4/2/2010
Response: The FAA reviewed the service history of uncommanded ATSV-Open events and found that, early in the MD-80 history, there had been a problem with the starter valves’ opening at a very high pneumatic duct pressure. This issue was addressed by Boeing Service Bulletins (SBs) DC9-80-010, directing reinstallation of a regulating feature, and DC9-80-014, directing installation of a pressure relief valve, both dated August 22, 1997. The FAA subsequently issued Airworthiness Directive (AD) 98-09-19, which required compliance with both SBs by June 3, 2000. Since the issuance of AD 98-09-19, two events have been reported involving uncommanded in-flight opening of the ATSV, including the American Airlines flight 1400 accident. Both events were attributed to failed filters’ not having been serviced at the previous C-check, the required interval. The FAA’s review of the service history satisfies the intent of the first part of this recommendation. The FAA indicated that, in response to the second part of this recommendation, it is currently evaluating the effectiveness of additional alerts for an ATSV-Open indication, including the implications of these alerts with respect to distractions and flight crew workload during critical phases of flight. After the evaluation is completed, the FAA will determine an appropriate response. Pending completion of these actions, Safety Recommendation A-09-21 is classified OPEN -- ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 8/11/2009
Response: Letter Mail Controlled 8/31/2009 2:09:47 PM MC# 2090551: - From J. Randolph Babbitt, Administrator: The Federal Aviation Administration has reviewed the service history of uncommanded ATSV-Open events. Early in the MD-80 history there was a problem with the starter valves opening at a very high pneumatic duct pressure. This issue was addressed by Boeing Service Bulletins (SBs) DC9-80-010, requiring reinstallation of a regulating feature, and DC9-80-014, requiring installation of a pressure relief valve, both dated August 22, 1997. Both SBs were mandated by Airworthiness Directive (AD) 98-09- 19, effective June 3, 1998, requiring compliance by June 3, 2000. Since the issuance of AD 98-09-19, two events were reported to Boeing involving uncommanded in-flight opening of the ATSV, which includes the event that prompted this recommendation. Both events were attributed to failed filters not serviced at the previous C-check, the required interval. As recommended, we will evaluate the effectiveness of additional alerts for an ATSV-Open indication. We will also evaluate the implications of those alerts with respect to distractions and flightcrew workload during critical phases of flight. Once an evaluation has been completed, we will determine an appropriate course of action, as necessary.