Re: ETOPS

From:         Sten Lasu <sten@lasu.pp.se>
Organization: Telia Internet Services
Date:         03 Nov 96 19:56:55 
References:   1 2 3 4
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Karl Swartz wrote:
> >As I recall, about 10 years ago, an aircraft (DC10 or L1011, can't
> >remember which) suffered catastrophic loss of engine oil pressure
> >somewhere in the region of the Caribbean. Two out of the three engines
> >were shut down. The remaining engine lasted long enough to reach a safe
> >landing, though it too was suffering loss of oil pressure--a critical
> >component had been wrongly installed in all three engines.
>
> It was an Eastern L-1011, flying from Miami to San Juan.  I don't have
> the date but I thought it was in the 1970s.  (Details appreciated if
> anyone can supply them.)

Details on L-1011 incidents can be found on the "Unofficial L-1011
homepage"   http://rampages.onramp.net/~gerhard/tristar/

This may be the incident you were looking for:
__________________________________________________________________
May 5, 1983 - Loss Of Oil Pressure In All Three Engines

193A-1141 as N334EA

Eastern Airlines flight 855

>From a college paper by Tim A. Krell

"May 5, 1983. An Eastern Airlines L-1011 was en route from Miami to Nassau.
The plane was at 23,000 feet and was starting its decent to Nassau.
Suddenly an indicator light came on, announcing that the oil pressure in
the Number 2 engine was dropping. The crew shut down the engine. Okay, no
problem. The plane can still fly with only one engine out. However, in a
few moments, the oil pressure started dropping on the Number 3 engine.
The crew eased the power to the number 3 engine, but didn't shut it off
completely. Okay. Still no problem. The plane can still run with an engine
out, and one engine partially on. But then, the number 1 engine stopped
rather abruptly.  Okay, were still all right. In a few moments, the number
3 engine then quit. Okay, we still got the number 4 engine, right? Well,
unfortunately, the L-1011 only has three engines. Now we do have a problem.
The plane began to drop about 1,200 feet a minute, and needless to say,
the people decided that this might perhaps be an opportune time to put on
their life vests and read the safety information card. As the plane was
about 3,900 feet above the Atlantic Ocean (they started at 23,000,
remember) the Number 2 tail engine finally sputtered back to life and the
plane was able to make a safe (and dry) emergency landing in Miami. Whew!

"Why did the engines quit? It was due to an "oversight" by the maintenance
men. Much to the chagrin of these conscientious, hard-working individuals,
it was later discovered that they had forgotten to put oil seals on the
oil plugs. Oops! I hate it when that happens! With the seal not in place,
the oil can freely leak from the engine.

"The mechanics said that they would have noticed the missing O-rings, as
they are called, if they had been doing their work in the daytime.  You
see, they had to do their maintenance work late at night with flashlights
and the lights of a pickup truck. Now do you think somebody's cutting
costs where it comes to maintenance? No, of course not.

"This was only the fourth incident of missing O-rings for Eastern. But in
the finest tradition of "we never make the same mistake twice--er, I mean
five times--in a row" Eastern finally got their act together.  (But for
how long?)"

The oil plugs referred to in the piece were actually the Chip Detectors.
The Chip Detectors are located in several points in the oil system and
are routinely removed by mechanics to check for metal particles in the
engine oil. Metal in the oil is a sure sign that the engine is starting
to come apart. The metal can then be analyzed to determine where the metal
came from and how much longer the engine can remain in service.

The problem occurs when the O-rings that are supposed to seal the chip
detector and keep it from leaking are damaged or not installed. In this
case, none of the chip detectors removed that night had O-rings on them
when they were reinstalled.

Did you catch the part about the mechanics saying this wouldn't have
happened if they wouldn't have been working at night with flashlights and
pickup truck lights? Guess what? We still work that way.

Human factors are always taken into consideration in an accident involving
pilot error and changes are made to help prevent the same thing from
happening. Human factors involving an accident caused by maintenance
receive lip-service, but action to change the problem are rare.

The pilot is responsible for the passengers, flight attendants and the
airplane.  The mechanic is responsible for the passengers, flight
attendants, airplane and the pilot!

Keep that in mind the next time you watch a mechanic working on your
airplane outside, at night and in the rain.

Additional Information: Aviation Week & Space Technology (AW&ST) July
23, 1984 Page 163-182 and Aug 13, 1984 page 185-219

NTSB Identification: MIA83AA136 For details, refer to NTSB microfiche
number
                                   23663A

          Scheduled 14 CFR 121 operation of EASTERN AIRLINES, INC.
                  Incident occurred MAY-05-83 at MIAMI, FL
              Aircraft: LOCKHEED L-1011, registration: N334EA
                          Injuries: 172 Uninjured.

Descending thru 15000 ft into Nassau the #2 eng was shut down due to low
oil press. At 16000 ft returning to Miami the #3 eng flamed out, & 3 min
later the #1 eng flamed out. The acft began descending without power from
13000 ft. At about 10000 ft the flightcrew announced that ditching was
imminent.  The #2 eng was restarted at 4000 ft, & the acft made a one-eng
landing at Miami. All o-ring seals in the master chip detector assy's in
the eng lubrication system were missing causing oil leaks in all engs.
Proper procedures to remove, reinstall & inspect the detectors for oil
leaks were available. The foreman knew that mechanics were not routinely
replacing o-ring seals. Accident was 9th chip detector occurrence since
procedures were revised 12/81. FAA aware of problems on EAL acft but did
not assign special surveillance priority to them. Attendants not aware of
time available to prepare cabin for ditching. Pax had difficulty locating
& donning life vests.

Probable Cause

Lubricating system,oil magnetic plug..Incorrect
Procedures/directives..Not followed..Company maintenance personnel
Maintenance,installation..Improper..Company maintenance personnel
Supervision..Inadequate..Company maintenance personnel
Unsafe/hazardous condition..Not corrected..Company/operator management
Lubricating system,oil magnetic plug..Leak
Fluid,oil..Starvation
Accessory drive assy,extension unit..Overtemperature
Accessory drive assy,extension unit..Failure,total
Accessory drive assy,ext shaft bearing..Not engaged
Fuel system,pump..Disabled
Fluid,fuel..Starvation

Contributing Factors

Inadequate surveillance of operation..FAA(organization)
Aircraft performance,two or more engines..Failure,total
_____________________________________________________________________

Martin Lasu
Stockholm,SWEDEN