Engine fire, St-Louis, plane evacuated,
I'm on my third jet type now, and all of them have shared this: if you have a fire warning, treat it as real. Shut it down (whether by the fire handle, or in one case by the normal shutdown immediately followed by the fire handle), and if the warning stops before you fire the bottle, great, don't fire the bottle. I don't know of any where you might keep the engine running, even at idle, although I stand to be corrected
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No shutdown ! Bull**** , in my opninion.
For 747, Boeing procedures clearly state in case of an engine fire :
T/L ; idle
Fuelcontrolswitch ; cut-off
Fire warning handle; pull
etc.
You identify the engine on fire together with your mate, and it is indicated RED on the fuelcontrol switch and the fire handle.
For 747, Boeing procedures clearly state in case of an engine fire :
T/L ; idle
Fuelcontrolswitch ; cut-off
Fire warning handle; pull
etc.
You identify the engine on fire together with your mate, and it is indicated RED on the fuelcontrol switch and the fire handle.
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I have never flown an MD80, or any Douglas aircraft, and I am unlikely to (not because there is anything wrong with them, just that they are unlikely to be added to the fleet of my current employer), therefore I cannot comment on the engine fire drill quoted by md100. I confess to being surprised, but I did say I stood to be corrected.
However, on my current type and both previous aircraft, the fire drill included verifying which engine, then at the appropriate time always shutting it down.
If MD fire detection systems were so robust as to allow an alternative option as listed by md100, then this would account for some of the respect shown to them by md- and dc- pilots.
However, on my current type and both previous aircraft, the fire drill included verifying which engine, then at the appropriate time always shutting it down.
If MD fire detection systems were so robust as to allow an alternative option as listed by md100, then this would account for some of the respect shown to them by md- and dc- pilots.
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Well I guess a leak in the pneumatic system from the engine could heat enough as to fire the "fire loops" and ring the bell (like the song), so idling the engine can relief the hot pressure there, so it would not be necesary to shut the engine down...but you may ask, Why having a stupid engine?? 1) maybe, as someone said, no shutting the wrong engine, 2) maybe necesary just in case, so you can have some extra power 3) the systems associated to that engine wil keep running...
but if it is a real fire, you will shut the engine down, like every jet in the world.
but if it is a real fire, you will shut the engine down, like every jet in the world.
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there is a scenario in which the engine problem can be solved with a power reduction...thus reducing the bleed air leak to levels below the fire warning requirements.
I've flown P&W on both the dc9 and the 737 and both had similiar concepts...if the warning stops with power idled, you may leave the engine running.
however, this one seems to be a fire as the bottles were shot and the fire department foamed to stop the remaining sparks.
I also think I wouldn't have evacuated via slides for the situation as we presently see it...more danger of pax injuries
I doubt anyone will read or respond to this post as I seem to be censured.
I've flown P&W on both the dc9 and the 737 and both had similiar concepts...if the warning stops with power idled, you may leave the engine running.
however, this one seems to be a fire as the bottles were shot and the fire department foamed to stop the remaining sparks.
I also think I wouldn't have evacuated via slides for the situation as we presently see it...more danger of pax injuries
I doubt anyone will read or respond to this post as I seem to be censured.
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Hi guys...
AA1400 suffered a "runaway" starter motor that ended up exploding out through the top of the engine, taking out the left generator and screwing up the left hydraulic system as well. If that wasn't bad enough, on finals the nose gear wouldn't extend so they performed a single engine go around and cranked it down manually, before landing without incident.
The start valve was wired shut (deferred) by maintenance a few days earlier. Somehow, the valve opened whilst the aircraft was climbing through 2500msl, and the ram air coming in the wrong entrance spun the starter up to a very high, destructive RPM that eventually made it come out through the top of the engine. That caused the fire and the damage.
This crew should be exempt from their recurrent training this year! Job well done.
73
AA1400 suffered a "runaway" starter motor that ended up exploding out through the top of the engine, taking out the left generator and screwing up the left hydraulic system as well. If that wasn't bad enough, on finals the nose gear wouldn't extend so they performed a single engine go around and cranked it down manually, before landing without incident.
The start valve was wired shut (deferred) by maintenance a few days earlier. Somehow, the valve opened whilst the aircraft was climbing through 2500msl, and the ram air coming in the wrong entrance spun the starter up to a very high, destructive RPM that eventually made it come out through the top of the engine. That caused the fire and the damage.
This crew should be exempt from their recurrent training this year! Job well done.
73
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?? JT8D Starter Valve again ??
Seems that several customers once didn't have any START VALVE OPEN annunciator on TBC product [starter cut-out verified manually (by a pilot) watching the Pneumatic Duct Pressure Indicator]. In the early 1980s, the automated form of alerting mechanism (Start Valve OPEN) was absent on some operators aircraft.
Their operator's MEL (or MxProcedure) likely doesn't mention anything about "wiring shut" the Starter Valve. Worse, the DC-9’s JT8D’s Valve Position Indicator is hidden: located on the engine-side of Start Valve -- requiring an inspection mirror for actual visual verification of engine-mounted Valve Position INDICATOR. Since we have not had many cases recently (JT8D slowly goes to salvage), regulator and operators may have forgotten lessons of the ‘70’s and ‘80’s.
I can't find any major accident with JT8D due to Start Valve negligence, but here’s an analogous case on a Russian product:
Baikal Air/ 3Jan94 Tu-154M crashed near Irkutsk Airport in Siberia, BBC reported 111 pax and 9 crew (later "Flt Int'l" repts claimed 125 killed), reported #2 engine failure, lost control. P.C.= overspeed of engine STARTER Turbine Disc; disc broke-free, sawed through center engine. Tail mounted Engine caught fire, heat destroyed triplex hydraulic system. Crew had elected to takeoff DESPITE a warning-indication of a Starter unit malfunction (overspeed): crew disregarded the warning, convinced that the Starter Unit could NOT be still running. Starter: metal fragment (from the Starter Cooling radiator) JAMMED-OPEN the pneumatic start valve. (Later, CVR had crew discussing the warning light indicating overspeed of the engine starter; but it had illuminated 2 minutes after start. Captain decided to proceed with the flight, aircraft manual only addressed such a warning during Start. Discussion also included references to the airlines difficulty in getting another aircraft. ["ORAP" = Society of Air Accident Investigators, in Russia.]
For the JT8D, the Starter Valve ANNUNCATION failure presents varying a MEL/MxProcedure -- differing for that light failed ON (illuminated); vs failed OFF (extinguished) [80-1]; or the third case of the Valve inoperative [80-2].
About ten years ago the FAA admitted to some lack of agency "COMPETENCY" while reviewing a Douglas-- JT8D incident, re' MEL oversight:
= = = \/ = = = EXCERPT = = = \/ = = =
ACCIDENT AND INCIDENT DATABASE
Report Number: 19961217044949C
17-DEC-96, AUSTIN, NWA, DC-9-31, 9605 ...
“... START VALVE STAYED OPEN AFTER #2 ENGINE WAS STARTED.
“MAINTENANCE CLOSED THE VALVE MANUALLY AS PER MEL 80-2 AND 80-1.
“AFTER TAKE OFF AND DURING CLIMB, THE START VALVE AGAIN OPENED INTERMITTENTLY. THE STARTER THEN DISENTEGRATED DOING DAMAGE TO THE ENGINE COWLING AND CAUSING A FIRE. ENGINE WAS SHUT DOWN, AGENT DISCARDED [sic] AND AIRCRAFT RETURNED TO AUSTIN.
“ IT WAS DISCOVERED THAT NWAA APPROVED MEL HAS NO PROVISION TO ELECTRICALLY ISOLATE THE STARTER CONTROL VALVE.
“AGENCY COMPETENCY. MEL HAS NO PROVISION TO ELECTRICALLY ISOLATE THE STARTER CONTROL VALVE AS ALL OTHER CARRIERS HAVE.” [accusing words quoted from FAA dB]
Their operator's MEL (or MxProcedure) likely doesn't mention anything about "wiring shut" the Starter Valve. Worse, the DC-9’s JT8D’s Valve Position Indicator is hidden: located on the engine-side of Start Valve -- requiring an inspection mirror for actual visual verification of engine-mounted Valve Position INDICATOR. Since we have not had many cases recently (JT8D slowly goes to salvage), regulator and operators may have forgotten lessons of the ‘70’s and ‘80’s.
I can't find any major accident with JT8D due to Start Valve negligence, but here’s an analogous case on a Russian product:
Baikal Air/ 3Jan94 Tu-154M crashed near Irkutsk Airport in Siberia, BBC reported 111 pax and 9 crew (later "Flt Int'l" repts claimed 125 killed), reported #2 engine failure, lost control. P.C.= overspeed of engine STARTER Turbine Disc; disc broke-free, sawed through center engine. Tail mounted Engine caught fire, heat destroyed triplex hydraulic system. Crew had elected to takeoff DESPITE a warning-indication of a Starter unit malfunction (overspeed): crew disregarded the warning, convinced that the Starter Unit could NOT be still running. Starter: metal fragment (from the Starter Cooling radiator) JAMMED-OPEN the pneumatic start valve. (Later, CVR had crew discussing the warning light indicating overspeed of the engine starter; but it had illuminated 2 minutes after start. Captain decided to proceed with the flight, aircraft manual only addressed such a warning during Start. Discussion also included references to the airlines difficulty in getting another aircraft. ["ORAP" = Society of Air Accident Investigators, in Russia.]
For the JT8D, the Starter Valve ANNUNCATION failure presents varying a MEL/MxProcedure -- differing for that light failed ON (illuminated); vs failed OFF (extinguished) [80-1]; or the third case of the Valve inoperative [80-2].
About ten years ago the FAA admitted to some lack of agency "COMPETENCY" while reviewing a Douglas-- JT8D incident, re' MEL oversight:
= = = \/ = = = EXCERPT = = = \/ = = =
ACCIDENT AND INCIDENT DATABASE
Report Number: 19961217044949C
17-DEC-96, AUSTIN, NWA, DC-9-31, 9605 ...
“... START VALVE STAYED OPEN AFTER #2 ENGINE WAS STARTED.
“MAINTENANCE CLOSED THE VALVE MANUALLY AS PER MEL 80-2 AND 80-1.
“AFTER TAKE OFF AND DURING CLIMB, THE START VALVE AGAIN OPENED INTERMITTENTLY. THE STARTER THEN DISENTEGRATED DOING DAMAGE TO THE ENGINE COWLING AND CAUSING A FIRE. ENGINE WAS SHUT DOWN, AGENT DISCARDED [sic] AND AIRCRAFT RETURNED TO AUSTIN.
“ IT WAS DISCOVERED THAT NWAA APPROVED MEL HAS NO PROVISION TO ELECTRICALLY ISOLATE THE STARTER CONTROL VALVE.
“AGENCY COMPETENCY. MEL HAS NO PROVISION TO ELECTRICALLY ISOLATE THE STARTER CONTROL VALVE AS ALL OTHER CARRIERS HAVE.” [accusing words quoted from FAA dB]
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Wow. Well, apparently this has happened before. I believe there is some form of FAA mandate for all US registered DC9/MD80 aircraft that has to do with some new type of starter/start valve.
On the aircraft in question (N454AA, the one which landed in JFK three years ago with no nose gear... not a good life so far!), the L START VALVE OPEN did not come on during engine start a week ago, which prompted the write up and subsequent deferral of the start valve.
That Balkan flight... what a tragic event!
73
On the aircraft in question (N454AA, the one which landed in JFK three years ago with no nose gear... not a good life so far!), the L START VALVE OPEN did not come on during engine start a week ago, which prompted the write up and subsequent deferral of the start valve.
That Balkan flight... what a tragic event!
73
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PC due next week
Need some good Tech' reporters on this, this case involves several interesting failure interactions, not anticipated by the designer, and not comprehended by the human operator (the preliminary reports didn't expose several of these system failures).
from the NTSB site:
NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
April 2, 2009
NTSB TO MEET ON JETLINER ACCIDENT INVOLVING ENGINE FIRE AND EMERGENCY RETURN TO AIRPORT
The National Transportation Safety Board will hold a public Board meeting on its investigation into an accident in which the crew of an American Airlines jetliner, which experienced an engine fire shortly after take-off, declared an emergency and returned to the airport. No one was injured in the accident.
The purpose of the meeting will be to determine the probable cause of the accident and to consider proposed safety recommendations to reduce the likelihood of future such mishaps.
The meeting will be held in Washington on Tuesday, April 7, 2009, at 9:30 a.m. ET, in the NTSB Board Room and Conference Center at 429 L'Enfant Plaza, S.W.
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.
A live and archived webcast of the proceedings will be available on the Board's website at NTSB - Board Meetings. Technical support details are available under "Board Meetings." To report any problems, please call 703-993-3100 and ask for Webcast Technical Support.
A summary of the Board's final report, which will include its findings, probable cause and safety recommendations, will appear on the website shortly after the conclusion of the meeting. The entire report will appear on the website several weeks later.
Directions to the NTSB Board Room: Front door located on Lower 10th Street, directly below L'Enfant Plaza. From Metro, exit L'Enfant Plaza station at 9th and D Streets escalator, walk through shopping mall, at the CVS store (on the left), and take escalator (on the right) down one level. The Board room will be to your left.
###
Media Contact: Peter Knudson
202-314-6100
[email protected]
from the NTSB site:
NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
April 2, 2009
NTSB TO MEET ON JETLINER ACCIDENT INVOLVING ENGINE FIRE AND EMERGENCY RETURN TO AIRPORT
The National Transportation Safety Board will hold a public Board meeting on its investigation into an accident in which the crew of an American Airlines jetliner, which experienced an engine fire shortly after take-off, declared an emergency and returned to the airport. No one was injured in the accident.
The purpose of the meeting will be to determine the probable cause of the accident and to consider proposed safety recommendations to reduce the likelihood of future such mishaps.
The meeting will be held in Washington on Tuesday, April 7, 2009, at 9:30 a.m. ET, in the NTSB Board Room and Conference Center at 429 L'Enfant Plaza, S.W.
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.
A live and archived webcast of the proceedings will be available on the Board's website at NTSB - Board Meetings. Technical support details are available under "Board Meetings." To report any problems, please call 703-993-3100 and ask for Webcast Technical Support.
A summary of the Board's final report, which will include its findings, probable cause and safety recommendations, will appear on the website shortly after the conclusion of the meeting. The entire report will appear on the website several weeks later.
Directions to the NTSB Board Room: Front door located on Lower 10th Street, directly below L'Enfant Plaza. From Metro, exit L'Enfant Plaza station at 9th and D Streets escalator, walk through shopping mall, at the CVS store (on the left), and take escalator (on the right) down one level. The Board room will be to your left.
###
Media Contact: Peter Knudson
202-314-6100
[email protected]
Need some good Tech' reporters on this, this case involves several interesting failure interactions, not anticipated by the designer, and not comprehended by the human operator (the preliminary reports didn't expose several of these system failures).
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complex failure interactions and botched investigations
from lampso, just above:
"...What's a Tech reporter gonna do ...?"
There have been some botched cases in the past few years, where a Board's field-office attempted the investigation, without sufficient assistance nor background.
I'm afraid this case (28Sep07) is an exemplar, too complicated for USA's Board. As you can see, the board switched the case away from CHI in April'08. Lately its been difficult to get the Board to correct errs, so if they botch this one, maybe the press will catch-it, and we won't have another botched case lingering in the records. [You might have noticed, at Halifax, the Board mentioned this case as one focus of their quality control test.]
"...What's a Tech reporter gonna do ...?"
There have been some botched cases in the past few years, where a Board's field-office attempted the investigation, without sufficient assistance nor background.
I'm afraid this case (28Sep07) is an exemplar, too complicated for USA's Board. As you can see, the board switched the case away from CHI in April'08. Lately its been difficult to get the Board to correct errs, so if they botch this one, maybe the press will catch-it, and we won't have another botched case lingering in the records. [You might have noticed, at Halifax, the Board mentioned this case as one focus of their quality control test.]
Bleed Air Leaks Are DANGEROUS!
Well I guess a leak in the pneumatic system from the engine could heat enough as to fire the "fire loops"...
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HP stage bleed air may be on the order of 1000 F or higher, potentially 500 psi on 777-class engines - the numbers speak for themselves.
But everything is relative. This same air source IS USED TO COOL the HP turbine airfoils, bathed in 2500+ F gas stream.
But everything is relative. This same air source IS USED TO COOL the HP turbine airfoils, bathed in 2500+ F gas stream.
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Start valve air filter caused chain of events; Maintenance and flight crew faulted.
This is a classic case (as reported in the news) of a minor malfunction leading to a significant safety event.
Malfunctions leading to a failure of a starter motor are anticipated and layers of minimization incorporated. Even the uncontained failure of a starter motor is anticipated and its consequences minimized and/or mitigated, including the penetration of a fuel system, leakage, ignition and subsequent fire. However since there are numerous malfunctions of powerplant systems that can result in a fuel leak, ignition and fire, the critical system that are anticipated to work a high percentage of the time are fire detection and fire suppression.
In my view these are the most serious lapses of all in this event and must be addressed at a much higher priority than all the rest of the findings/recommendations. Unfortunately the NTSB political appointed Board members have a tendancy to meld all their recs together and promote those with the most news worthy appeal.
Malfunctions leading to a failure of a starter motor are anticipated and layers of minimization incorporated. Even the uncontained failure of a starter motor is anticipated and its consequences minimized and/or mitigated, including the penetration of a fuel system, leakage, ignition and subsequent fire. However since there are numerous malfunctions of powerplant systems that can result in a fuel leak, ignition and fire, the critical system that are anticipated to work a high percentage of the time are fire detection and fire suppression.
In my view these are the most serious lapses of all in this event and must be addressed at a much higher priority than all the rest of the findings/recommendations. Unfortunately the NTSB political appointed Board members have a tendancy to meld all their recs together and promote those with the most news worthy appeal.
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Wall Street Journal article. No good deed goes unpunished.
http://online.wsj.com/article/SB123911699635497099.html
Mistakes by American Airlines mechanics and pilots led to the emergency landing of a fire-damaged jet two years ago in St. Louis, according to federal accident investigators.
In the September 2007 nonfatal incident, the American McDonnell Douglas MD-82 had a fire in one of its two engines shortly after takeoff from Lambert-St. Louis International Airport, and also suffered hydraulic and electrical malfunctions. The plane with 143 people aboard returned and landed safely at the airport after pilots managed to manually lower the nose gear.
Members of the National Transportation Safety Board said during a hearing in Washington Tuesday that the accident revealed systemic problems with the carrier's maintenance practices. "Why wasn't there a red flag" to identify and track repeated problems that led to the emergency, asked board member Kathryn Higgins. "I find that very troubling."
American Airlines mechanics repeatedly replaced a pneumatic start valve on the left engine before the accident—replacing it six times in 13 days—but failed to get to the bottom of the problem. By using improper procedures to start the engine on the ground, mechanics ended up damaging a mechanism attached to the engine, which sparked the fire that resulted in the emergency.
In addition to those unauthorized procedures, the board's final report cites misguided pilot actions that led to delays in going through an emergency checklist, increasing the risks from the initial engine fire. The board also cited "deficiencies' in the carrier's maintenance oversight as a contributing factor.
American, a unit of AMR Corp., months ago changed some maintenance practices, and it replaced and began modifying certain parts to prevent a repeat of the problems. After the hearing, a spokesman said the company also has enhanced pilot training and increased efforts to audit maintenance reports, partly as a result of lessons learned. Spokesman Tim Wagner said the board criticized employees who failed to follow rules, rather than the procedures themselves.
Still, Tuesday's hearing shined a spotlight on American's operations at a time when the carrier is under heightened scrutiny from the Federal Aviation Administration. American has had a series of maintenance lapses in the past year, and the FAA is conducting a special audit of the carrier similar to those already finished at some U.S. rivals.
"If this had been a fatal accident," American's maintenance tracking and oversight system "would be facing more scrutiny," said board member Deborah Hersman. "They had multiple times to address the problem," but failed to identify a permanent fix, she said.
The board's staff criticized the pilots for failing to follow emergency procedures, "squandering" nearly two minutes with extraneous tasks, such as dealing with a cockpit door that became unlocked, and failing to properly divide up duties. Some of the crew's actions made the emergency more serious, according to investigators, by causing hydraulic problems.
Board member Robert Sumwalt, a former airline pilot, faulted the crew for a "relaxed and casual attitude," including a failure to adhere to proper checklists and engaging in extraneous talk while taxiing out for takeoff. "They weren't ready to handle what got thrown to them." Sumwalt said.
In spite of their missteps, the experienced pilots on American Airlines Flight 1400 showed "exceptional stick and rudder skills' that allowed the aircraft to land safely, said Mark Rosenker, the board's acting chairman.
The board's final report is likely to have broad implications, partly because it asks the FAA to consider changing training procedures industrytwide to show pilots how to effectively deal with different system failures at the same time. The accident report also urges consideration of modifying the MD-80 family of aircarft to make it easier for pilots to identify midair problems with engine-start valves. And it urges American to reassess its maintenance tracking "and make necessary modifications to the program to correct these shortcomings."
Write to Andy Pasztor at [email protected]
http://online.wsj.com/article/SB123911699635497099.html
Mistakes by American Airlines mechanics and pilots led to the emergency landing of a fire-damaged jet two years ago in St. Louis, according to federal accident investigators.
In the September 2007 nonfatal incident, the American McDonnell Douglas MD-82 had a fire in one of its two engines shortly after takeoff from Lambert-St. Louis International Airport, and also suffered hydraulic and electrical malfunctions. The plane with 143 people aboard returned and landed safely at the airport after pilots managed to manually lower the nose gear.
Members of the National Transportation Safety Board said during a hearing in Washington Tuesday that the accident revealed systemic problems with the carrier's maintenance practices. "Why wasn't there a red flag" to identify and track repeated problems that led to the emergency, asked board member Kathryn Higgins. "I find that very troubling."
American Airlines mechanics repeatedly replaced a pneumatic start valve on the left engine before the accident—replacing it six times in 13 days—but failed to get to the bottom of the problem. By using improper procedures to start the engine on the ground, mechanics ended up damaging a mechanism attached to the engine, which sparked the fire that resulted in the emergency.
In addition to those unauthorized procedures, the board's final report cites misguided pilot actions that led to delays in going through an emergency checklist, increasing the risks from the initial engine fire. The board also cited "deficiencies' in the carrier's maintenance oversight as a contributing factor.
American, a unit of AMR Corp., months ago changed some maintenance practices, and it replaced and began modifying certain parts to prevent a repeat of the problems. After the hearing, a spokesman said the company also has enhanced pilot training and increased efforts to audit maintenance reports, partly as a result of lessons learned. Spokesman Tim Wagner said the board criticized employees who failed to follow rules, rather than the procedures themselves.
Still, Tuesday's hearing shined a spotlight on American's operations at a time when the carrier is under heightened scrutiny from the Federal Aviation Administration. American has had a series of maintenance lapses in the past year, and the FAA is conducting a special audit of the carrier similar to those already finished at some U.S. rivals.
"If this had been a fatal accident," American's maintenance tracking and oversight system "would be facing more scrutiny," said board member Deborah Hersman. "They had multiple times to address the problem," but failed to identify a permanent fix, she said.
The board's staff criticized the pilots for failing to follow emergency procedures, "squandering" nearly two minutes with extraneous tasks, such as dealing with a cockpit door that became unlocked, and failing to properly divide up duties. Some of the crew's actions made the emergency more serious, according to investigators, by causing hydraulic problems.
Board member Robert Sumwalt, a former airline pilot, faulted the crew for a "relaxed and casual attitude," including a failure to adhere to proper checklists and engaging in extraneous talk while taxiing out for takeoff. "They weren't ready to handle what got thrown to them." Sumwalt said.
In spite of their missteps, the experienced pilots on American Airlines Flight 1400 showed "exceptional stick and rudder skills' that allowed the aircraft to land safely, said Mark Rosenker, the board's acting chairman.
The board's final report is likely to have broad implications, partly because it asks the FAA to consider changing training procedures industrytwide to show pilots how to effectively deal with different system failures at the same time. The accident report also urges consideration of modifying the MD-80 family of aircarft to make it easier for pilots to identify midair problems with engine-start valves. And it urges American to reassess its maintenance tracking "and make necessary modifications to the program to correct these shortcomings."
Write to Andy Pasztor at [email protected]
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2-Pilot Cockpit relies on AUTOMATED safety features
Re' the BOARD's Sunshine Hearing (7Apr09) of this MD80 28Sep07 DCA07MA310 ----
I’m hoping the final AAR is of better quality than the cursory TECHNICAL presentation during the Board’s Sunshine Hearing. I generally start worrying about the quality of Board’s TECHNICAL investigation whenever they trot-out the Human Factors guys to focus on PILOTS.
One of the Board members is a long standing, and recognized member of the accident investigation community, and I’ve always admired Sumwalt’s contributions: but he was mostly involved in the HF side of investigations.
Imagine how this Sunshine Hearing might have been presented -- if any one of the Board Members, had instead, past experience as part of the engineering/ CERTIFICATION community, during the late 1970’s and early -80’s, just after the Presidential Commission completed their STUDY of the safety of future 2-Pilot Cockpit.
Recall the basis of the 2-Pilot concept: No Flight Engineer , no 3rd pilot would be needed in the B767 Cockpit (Douglas was working the MD80 development at the same time).
Back then, the argument was that the 2-pilot cockpit would continue as safe as the 3-pilot cockpit – because of AUTOMATIC safety features designed into the 2-pilot cockpit. FAA pilots flew along on test flights, FAA ACO engineers came along, and we were always under the mandate that the AUTOMATIC features must perform their intended function: operate reliably, to provide a level of safety, AS SAFE AS a cockpit with that former Flight Engineer’s position.
Once the 2-pilot airliner is delivered to the operator, we depend upon the AIRLINE to maintain the AUTOMATIC safety features (AC CrossTie RELAY, APU Generator Relay), and we depend upon pilots to reject any aircraft where these automated safety features are routinely unreliable (remember, you are NOT meant to play the role of FE).
Now after reviewing the failure interactions during the MD80 mishap of 28Sep07 (loss of the Left AC Bus, loss of BOTH Hydraulic Systems, after merely a failure of the Left Engine) ask yourself if the original CERTIFICATION precepts have been abandon. It seems to me that the operator, the regulator, and the Board should focus more on some of the TECHINICAL failures in our original ENGINEERED SAFETY FEATURES:
Had the “2-Pilot COCKPIT” automated safety features operated as designed, then this mishap would have been much simpler, and those MD80 pilots would have had normal ELECTRICAL and HYDRAULIC systems, and completed their immediate return for landing, without the Go-Around (due to Gear and Flap anomalies) with an active FIRE indication.
= = = = = = = = = = = =
Document are available in Docket:
http://www.ntsb.gov/Dockets/Aviation/DCA07MA310/default.htm
From the Boeing Submission, pgs 7-8, under heading “Electrical Systems”, describing faults during the mishap flight:
Capt’s second interview dated May 1, 2008, Phone interview
Ops Gp Factual, Attch 1, Pg 22:
[Pilot mentioned the unusual Pilot- STICK and -RUDDER FORCE required due to Thrust asymmetry, manual Rudder, Elevator Column FORCE needed to counter depowered HorizStab Pitch Trim.]
F/O’s statement during second interview
Date: May 1, 2008
Location: Phone Interview
Time: 1100 edt
Attachment 1 pg28:
Edit -- the final NTSB/AAR-09/03 was released:
Unfortunately the NTSB staff failed to present the Board Members with any history of the certification precepts for the "2-Pilot Cockpit", nor for the AUTOMATED safety features in the ELECTRICAL switching (NO F/E to manually repower the dead Left AC Bus). This AAR-09/03 reflects the NTSB's inability to investigate "system" electrical fault-interactions: Instead, the AAR delves into the human factors involving PILOTS, with no "analysis" of the failure of the aircraft's automated switching features: the Left AC Bus lost electrical power (failed function of AC CrossTie Relay and failed auto-function of the APU Gen Rely), and those failures in electrical relays made all the difference.
The Board Members should have asked for better performance from the NTSB-staff at the Sunshine Meeting, and demanded some explanation (in the AAR) of the failure of those automated electrical-switching features.
I’m hoping the final AAR is of better quality than the cursory TECHNICAL presentation during the Board’s Sunshine Hearing. I generally start worrying about the quality of Board’s TECHNICAL investigation whenever they trot-out the Human Factors guys to focus on PILOTS.
One of the Board members is a long standing, and recognized member of the accident investigation community, and I’ve always admired Sumwalt’s contributions: but he was mostly involved in the HF side of investigations.
Imagine how this Sunshine Hearing might have been presented -- if any one of the Board Members, had instead, past experience as part of the engineering/ CERTIFICATION community, during the late 1970’s and early -80’s, just after the Presidential Commission completed their STUDY of the safety of future 2-Pilot Cockpit.
Recall the basis of the 2-Pilot concept: No Flight Engineer , no 3rd pilot would be needed in the B767 Cockpit (Douglas was working the MD80 development at the same time).
Back then, the argument was that the 2-pilot cockpit would continue as safe as the 3-pilot cockpit – because of AUTOMATIC safety features designed into the 2-pilot cockpit. FAA pilots flew along on test flights, FAA ACO engineers came along, and we were always under the mandate that the AUTOMATIC features must perform their intended function: operate reliably, to provide a level of safety, AS SAFE AS a cockpit with that former Flight Engineer’s position.
Once the 2-pilot airliner is delivered to the operator, we depend upon the AIRLINE to maintain the AUTOMATIC safety features (AC CrossTie RELAY, APU Generator Relay), and we depend upon pilots to reject any aircraft where these automated safety features are routinely unreliable (remember, you are NOT meant to play the role of FE).
Now after reviewing the failure interactions during the MD80 mishap of 28Sep07 (loss of the Left AC Bus, loss of BOTH Hydraulic Systems, after merely a failure of the Left Engine) ask yourself if the original CERTIFICATION precepts have been abandon. It seems to me that the operator, the regulator, and the Board should focus more on some of the TECHINICAL failures in our original ENGINEERED SAFETY FEATURES:
-- The AC CrossTie Relay was designed to power the Buses of the failed Engine Generator;
-- The automated APU Generator RELAY shouldn’t need any attention from pilots in an MD80 cockpit, the AUTOMATIC features should have provided power to the Left AC Bus once the Captain had stroked the APU Start Switch from Off to START.
A 2-Pilot cockpit was designed for this one-stroke automation -- without inducing distractions to the FO, who was instead forced to take-on the added role of Flight Engineer, forced to investigate failed AUTOMATIC features, then RESET the APU Generator Relay.-- The automated APU Generator RELAY shouldn’t need any attention from pilots in an MD80 cockpit, the AUTOMATIC features should have provided power to the Left AC Bus once the Captain had stroked the APU Start Switch from Off to START.
Had the “2-Pilot COCKPIT” automated safety features operated as designed, then this mishap would have been much simpler, and those MD80 pilots would have had normal ELECTRICAL and HYDRAULIC systems, and completed their immediate return for landing, without the Go-Around (due to Gear and Flap anomalies) with an active FIRE indication.
= = = = = = = = = = = =
Document are available in Docket:
http://www.ntsb.gov/Dockets/Aviation/DCA07MA310/default.htm
From the Boeing Submission, pgs 7-8, under heading “Electrical Systems”, describing faults during the mishap flight:
“… In the event of a power loss on the load buses of either side, a crosstie relay is provided so that the unpowered buses can be connected to the power source energizing the buses of the opposite side…
“… function of the AC crosstie relay (ACTR) is to connect the left and right AC generator buses together under certain conditions, thereby permitting both buses to be energized by a single generator …
“If power is lost on one bus, the ACTR is designed to automatically close when the associated dead bus sensing circuit senses a loss of power on the bus….
“… FDR … is powered by the left AC bus, which … powered by the left engine-driven generator. Gaps in the FDR data indicate that the electrical power to the FDR was interrupted intermittently … data recording stopped for 22 seconds, then ran briefly for 3.5 seconds, then stopped again for 12 minutes … before returning … when APU powere came on the bus.”
Then on pg 8 of Boeing’s submission, under Flight Crew Items:“… function of the AC crosstie relay (ACTR) is to connect the left and right AC generator buses together under certain conditions, thereby permitting both buses to be energized by a single generator …
“If power is lost on one bus, the ACTR is designed to automatically close when the associated dead bus sensing circuit senses a loss of power on the bus….
“… FDR … is powered by the left AC bus, which … powered by the left engine-driven generator. Gaps in the FDR data indicate that the electrical power to the FDR was interrupted intermittently … data recording stopped for 22 seconds, then ran briefly for 3.5 seconds, then stopped again for 12 minutes … before returning … when APU powere came on the bus.”
“… crew had multiple opportunities to manage the event in a more effective manner. These opportunities were lost each time the crew failed to initiate and complete an appropriate checklist.”
Hmmm, this is the sort of input from the manufacturer meant to distract investigators -- this is where the good investigator should refocus on the TECHNICAL aspects of the case: don't let the HF guys take control!Capt’s second interview dated May 1, 2008, Phone interview
Ops Gp Factual, Attch 1, Pg 22:
“… the electrical problems … did not have the digital flight guidance panel … could not use the autopilot…. primary flight instruments were blacking out occasionally … cycled … Eventually his primary flight instruments stabilized and stayed on, but they were so erratic he did not really pay attention to them. There were a lot of lights that were not working and some were on. He felt he could not trust what the light indications were telling him. The whole electrical system was acting strange.
“… he started the APU … the APU would pick up the electrical load if it could…. He said the APU would pick up the electrical load or it wouldn’t…. if there was a reason it could not power a bus then it wouldn’t. It was one of those things where you start the APU and hope it works and if it does not work, there was nothing he can do about it. Initially, they were not getting power to the left side of the electrical system. The F/O eventually reset the APU generator control relay and they got electrical power back on the electrical bus. Normally the power was picked up automatically and you did not have to reset it. They got the power back on the left …”
Ops Gp Factual, Attch 1, Pg 25 :[Pilot mentioned the unusual Pilot- STICK and -RUDDER FORCE required due to Thrust asymmetry, manual Rudder, Elevator Column FORCE needed to counter depowered HorizStab Pitch Trim.]
“ with him [Captain] flying and the F/O running the engine fire checklist and talking on the radio was different than normally done…. usually … guy flying would fly the airplane and talk on the radio while the other pilot ran checklists…. things were not handled that way … difficulty controlling the airplane … in training, they always had the autopilot after an engine fire event, so it was easier to fly and talk and let other pilot handle the checklist. … the F/O … took it upon himself to talk …”
From Ops Groups Factual, Interviews, Attachment 1,F/O’s statement during second interview
Date: May 1, 2008
Location: Phone Interview
Time: 1100 edt
Attachment 1 pg28:
“… they lost the left AC bus when the engine was shut down and the system did not crosstie. The left side … completely dark. … a multitude of instruments that were ac or dc powered that were dead. … captain's navigational instruments were frozen or dead.
Gear indications … no green gear lights because the left ac bus was dead….
Pg 30:Gear indications … no green gear lights because the left ac bus was dead….
“… The APU started … but it did not go on-line electrically. … he reset the APU generator relay … electrical power did go to both sides of the electrical system. … captain’s instruments returned then. He did not recall if the hydraulic or flap gauges were working normally after the reset….”
= = = = = == = = = == == Edit -- the final NTSB/AAR-09/03 was released:
Unfortunately the NTSB staff failed to present the Board Members with any history of the certification precepts for the "2-Pilot Cockpit", nor for the AUTOMATED safety features in the ELECTRICAL switching (NO F/E to manually repower the dead Left AC Bus). This AAR-09/03 reflects the NTSB's inability to investigate "system" electrical fault-interactions: Instead, the AAR delves into the human factors involving PILOTS, with no "analysis" of the failure of the aircraft's automated switching features: the Left AC Bus lost electrical power (failed function of AC CrossTie Relay and failed auto-function of the APU Gen Rely), and those failures in electrical relays made all the difference.
The Board Members should have asked for better performance from the NTSB-staff at the Sunshine Meeting, and demanded some explanation (in the AAR) of the failure of those automated electrical-switching features.
Last edited by IGh; 23rd Aug 2012 at 20:48.
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Speaking of human factors
I for one find IGh's post very difficult to read, let alone comprehend, because of the frequent changes of font size, bold vs unbold, etc. It's a shame too, because I think he has a point to make, but that point is obscured by the typography.
barit1;
Me too. Copy the entire text, (select it all, press "CTRL C", open Notebook, press "CTRL V". All formatting will be gone. Under "format" in the menu bar, select "Word Wrap", and the text can be read more easily.
Me too. Copy the entire text, (select it all, press "CTRL C", open Notebook, press "CTRL V". All formatting will be gone. Under "format" in the menu bar, select "Word Wrap", and the text can be read more easily.
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I Had
less difficulty. I for one think the mobile fonts, emphasis etc. to be interesting and helped create a more expressive post. The interesting point was the reaction of Investigators, their agendas, all the competing factors in the promotion of an entirely new format and its implications in accidents and investigations. Good presentation.