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Safety Recommendation Details

Safety Recommendation A-09-029
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 AMERICAN AIRLINES: Evaluate your Continuing Analysis and Surveillance System program to determine why it failed to (1) identify deficiencies in its maintenance program associated with the MD-80 engine no-start failure and (2) discover the lack of compliance with company procedures. Then, make necessary modifications to the program to correct these shortcomings.
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: 1/11/2012
Addressee(s) and Addressee Status: American Airlines, Inc. (Closed - Acceptable Action)
Keyword(s): Engine, Maintenance, Oversight

Safety Recommendation History
From: NTSB
To: American Airlines, Inc.
Date: 1/11/2012
Response: Your letter described AAL’s comprehensive after-action event review, which identified improvements needed in your CASS program. These improvements, which included doubling the size of the staff in the CASS Analysis department, significantly increasing the number of data feeds being analyzed by CASS and automating the associated data analysis, were made in 2010. We are particularly pleased that, in October 2010, after these improvements had been instituted, AAL conducted a followup analysis to determine whether the corrective actions had been effective. The activities described in AAL’s letter fully satisfy Safety Recommendation A-09-29; accordingly, it is classified CLOSED—ACCEPTABLE ACTION.

From: American Airlines, Inc.
To: NTSB
Date: 12/2/2011
Response: -From David L. Campbell, Vice President of Safety, Security, and Environmental: I would like to apologize for the timeliness in our formal response to your May 2009 NTSB Safety recommendation. Our lack of written response was due solely to an internal miscommunication and is not in any way reflective of the level of importance that we place on safety related items in general and your recommendations in particular. Upon receipt of the NTSB recommendations in 2009, American Airlines undertook a comprehensive after-action event review to understand all of the causal factors that played a role in the Flight 1400 accident. The after action review focused on the initiating factors of the event, primarily the mechanical issues like the filter failure and the manual start push-button. It looked at the cultural aspects identified in the accident, like the failure to follow maintenance procedures, and the human factors that played a role, like complacency and common work-arounds that may lead an AMT to perform a task differently than prescribed in the maintenance documentation. Additionally, the review examined the company's current repeat control process and the factors that led to the MOC lack of awareness in this accident and the airlines inability to effectively troubleshoot and fi.x aircraft N454. And finally, it included a critical review of the airline's CASS program, and its role in the events of Flight 1400, its lack of oversight of the entire repeat control process and day-to-day monitoring and the role it should play in addressing procedural non-compliance in the airline. As a result of the after action review, numerous corrective actions were implemented to address the individual identified causal factors. Mechanical fixes were put in place to address the filter, its maintenance program and the manual override push button. Procedural changes were put in place to address the interface between MOC and line maintenance, allowing MOC to have greater control over returning repeating• aircraft to service. Numerous training courses were released to AMTs on the topic of adherence to the maintenance !program and procedural compliance. Long-term corrective actions were implemented to raise the overall level of compliance in the airline and focus on the timeliness of inputting data for MOC's review. Several items were tracked at the CASS Review Board level (Procedural Non-compliance~ Repeat Control, MD80 Engine Start valve Open Light, FMR Timeliness, Flight 1400 Follow-up Items) to ensure timely completion and verify effectiveness of the corrective action. In 2009 American Airlines also performed a detailed gap analysis with the existing CASS program and the Continuing Analysis and Surveillance System (CASS) Advisory Circular 120-79. At that time it was determined that there were several tasks enumerated in the Advisory Circular that American's CASS Analysis was not actively monitoring, repeating aircraft being one of them. To that end, in 2010 American Airlines doubled the size of the CASS Analysis department from 4 analysts to 8 analysts. The number of data feeds being analyzed by CASS were significantly increased and multiple processes were put in place to automate the data analysis, making it more easily reviewed, tracked and trended and escalated through upper management as necessary. In October 2010, a follow-up analysis was performed to determine if the causal factors identified in the Flight 1400 after action review were still factors and if the corrective action plans put in place to mitigate the effects of each individual factor could prevent a similar event from happening again in the future. Although certain factors remain within the American Airlines system, we feel that the airline that exists today is far less susceptible to fall victim to the events that unfolded on Flight 1400 in 2007. At American Airlines, we understand the role that mechanical malfunctions and human factors play in maintenance.• We employ a first-class Maintenance and Engineering organization to provide a safe, reliable product to our customers. We remain vigilant and aware of human factors as we understand we can never completely discount human fallibility. We strive to ensure that we have the appropriate controls in place to prevent incidents and accidents and have a robust continuous analysis and surveillance system to tell us when the controls are failing. We are committed to a culture of safety and compliance and strive ingrain this in our everyday operations.