Eastern Air Lines Flight 855
The aircraft involved in the incident
|Date||May 5, 1983|
|Summary||Multiple engine failures due to maintenance error|
|Aircraft type||Lockheed L-1011 TriStar 1|
|Operator||Eastern Air Lines|
|Flight origin||Miami International Airport|
|Destination||Nassau International Airport|
On May 5, 1983, a Lockheed L-1011 TriStar, registration N334EA, operating as Eastern Air Lines Flight 855 en route from Miami International Airport to Nassau International Airport, experienced the loss of all three engines near Miami, Florida. The flight crew succeeded in restarting one engine in time to safely land the aircraft at Miami International Airport.
The incident aircraft was a Lockheed L-1011 TriStar 1, registration N334EA, msn 1141. The aircraft had been manufactured in 1976. It was powered by three Rolls-Royce RB211-22B turbofan engines.
On May 4, N334EA had flown into Miami where it underwent overnight maintenance, which included a check of the magnetic chip detectors inside the jet engines. This involved removing the master chip detector from each engine and replacing it with a new one. Each chip detector had two O-rings, which served as oil seals. The replacement chip detectors were not fitted with O-rings, a fact which escaped the mechanic who fitted them. After the chip detectors were fitted, each engine was motored for 10 seconds to check for oil leaks. None were found. The aircraft was signed off as serviceable and returned to service.
Eastern Air Lines Flight 855 took off from Miami International Airport at 08:56 on a flight to Nassau International Airport in the Bahamas carrying 162 passengers and 10 crew. On board was a veteran flight crew, consisting of Captain Richard Boddy (58), Captain Steve Thompson (48) and Flight Engineer Dudley Barnes (44). Captain Boddy had more than 12,000 hours of total flying experience, although he was new to the L-1011, having logged just 13 hours in the aircraft type. On this flight, Captain Thompson served as a supervisory check airman. He had accrued close to 17,000 flight hours throughout his career, with 282 hours in the L-1011. Flight Engineer Barnes had more than 9,000 hours of total flying time, with 2,666 hours clocked in the L-1011 cockpit.
At 09:15, while descending through 15,000 feet (4,572 m), the low oil pressure indicator on the TriStar's number 2 engine illuminated. The flight engineer noted that the oil pressure on the #2 engine was fluctuating between 15 and 25 psi; the minimum pressure required for normal engine operation was 30 psi. The captain ordered the flight engineer to shut down the engine.
By this time, the plane was about 50 miles (80 km) from Nassau. The crew elected to return to Miami to land. Flight 855 received a clearance back to Miami, as well as instructions to begin a climb to FL200 (20,000 ft, 6,096 m nominal altitude).
En route back to Miami, low oil pressure lights for engines #1 and #3 illuminated, and the oil quantity gauges for all three engines read zero. At 09:23, Flight 855 informed Miami ARTCC of the engine gauge readings but stated, "We believe it to be faulty indications since the chance of all three engines having zero oil pressure and zero quantity is almost nil." At 09:28, at an altitude of 16,000 feet (4,877 m), the #3 engine failed. Five minutes later, the #1 engine flamed out while the crew was attempting to restart the #2 engine. Cabin lights went off and flight deck instruments stopped working. The aircraft descended without power from about 13,000 feet (3,962 m) to about 4,000 feet (1,219 m), at a rate of descent of approximately 1,600 feet (488 m) per minute. The crew successfully restarted the #2 engine on the third attempt and executed a one-engine landing at Miami at 09:46.:4 After the landing the power from #2 engine was insufficient for the aircraft to taxi; a tug had to be used to tow it to the airport terminal, where the occupants disembarked normally.:4 None of the 172 passengers and crew aboard were injured in the incident.
The National Transportation Safety Board determined that the probable cause of the incident was as follows:
[T]he omission of all the O-ring seals on the master chip detector assemblies leading to the loss of lubrication and damage to the airplane's three engines as a result of the failure of mechanics to follow the established and proper procedures for the installation of master chip detectors in the engine lubrication system, the repeated failure of supervisory personnel to require mechanics to comply strictly with the prescribed installation procedures, and the failure of Eastern Air Lines management to assess adequately the significance of similar previous occurrences and to act effectively to institute corrective action. Contributing to the cause of the incident was the failure of Federal Aviation Administration maintenance inspectors to assess the significance of the incidents involving master chip detectors and to take effective surveillance and enforcement measures to prevent the recurrence of the incidents.— NTSB Aircraft Accident Report AAR-84-04: Eastern Airlines, INC., Lockheed L-1011, N334EA
It was subsequently established that the engines needed to be run for at least 30 seconds with no O-rings fitted before an oil leak would become apparent.
- Stewart 1992, pp. 27-28.
- Ranter, Harro. "N334EA Accident description". aviation-safety.net. Aviation Safety Network. Retrieved June 28, 2013.
- Stewart 1992, p. 28.
- Stewart 1992, pp. 27-29.
- Stewart 1992, pp. 40-41.
- "Summary for Aircraft Accident Report AAR-84-04: Eastern Airlines, INC., Lockheed L-1011, N334EA". National Transportation Safety Board. March 9, 1984. Retrieved June 28, 2013.
- "Aircraft Accident Report: Eastern Airlines, INC., Lockheed L-1011, N334EA, Miami International Airport, Miami, Florida, May 5, 1983" (PDF). National Transportation Safety Board. March 9, 1984. NTSB/AAR-84/04. Retrieved June 28, 2013.
- Stewart 1992, p. 41.
- Stewart 1992, p. 50.
- Stewart, Stanley (1992). Emergency, Crisis on the Flight Deck. Shrewsbury: Airlife. ISBN 1-85310-348-9.CS1 maint: ref=harv (link)
- Airliners.net Photos of Eastern Air Lines Lockheed L-1011-385-1 TriStar aircraft
- National Transportation Safety Board