Office of Aviation Safety American Airlines Flight 1400 St. Louis, Missouri Captain David Tew Operational Factors.

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Presentation transcript:

Office of Aviation Safety American Airlines Flight 1400 St. Louis, Missouri Captain David Tew Operational Factors

ATSV-Open Light Crew noticed light after takeoff Crew discussed valve and light F/O responded to ATC Crew completed configuration clean-up Crew did not perform ATSV-Open checklist AA has modified alerting system

Engine Fire Warning Captain stated he would fly and F/O would perform engine fire checklist No one designated for radio F/O performed first two checklist items F/O interrupted checklist to respond to ATC Captain communicated with F/As Checklist interrupted for almost two minutes while fire continued to burn

Engine Fire Warning (cont.) Checklist interrupted before fuel shutoff or fire agent discharged Interruption a factor in electrical and hydraulic abnormalities Crew failed to complete checklist Hydraulic abnormality led to failure of nose gear to extend Go-around executed with fire indication still present

Pneumatic Crossfeed Valve F/O opened pneumatic crossfeed valve after landing Caused engine fire handle to retract Fuel re-introduced into engine Passengers deplaned Boeing manuals contained guidance on pneumatic crossfeed valve AA manuals lacked guidance