The National Transportation Safety Board (NTSB) has concluded that an engine fire that developed during a Sept. 2007 flight was likely due to an improper mechanical procedure and flawed safety management system that could have exposed the incorrect procedure. American Airlines Flight 1400, a McDonnell Douglas DC-9-82, took off from Lambert Airport in St. Louis on Sept. 28, 2007 and experienced a left engine fire. While returning to Lambert, the landing gear did not function, so the crew was forced to make an emergency landing. According to NTSB investigators, a mechanic had used an unapproved tool to start the left engine while at Lambert, damaging a component in the engine’s manual start mechanism, which triggered a series of events leading to the fire. In addition, the engine’s air turbine starter valve had been replaced six times in the days leading up to the accident, but none of the replacements fixed the problem. The airline’s continuing analysis and surveillance system (CASS), which is designed to “catch maintenance and mechanical issues that could lead to an incident or accident, failed to do what it was designed to do,” said NTSB Acting Chairman Mark Rosenker. “Following the appropriate maintenance procedures would have gone a long way toward preventing this mishap,” he added. NTSB issued a total of nine safety recommendations as a result of the incident, including that American review and correct deficiencies in its CASS program.
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