FLIGHT SAFETY FOUNDATION Aviation Mechanics Bulletin JULYÐAUGUST 1999

Omission of Oil-plug Seals Leads to In-flight Engine Shutdowns FLIGHT SAFETY FOUNDATION Aviation Mechanics Bulletin Dedicated to the aviation mechanic whose knowledge, craftsmanship and integrity form the core of air safety. Robert A. Feeler, editorial coordinator JulyÐAugust 1999 Vol. 47 No. 4

Omission of Oil-plug Seals Leads to In-flight Engine Shutdowns ...... 1 Maintenance Alerts...... 7 News & Tips ...... 10

On the cover: British Aerospace BAe 146

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The incident inquiry concluded that maintenance error caused oil to be lost from all four engines on a British Aerospace BAe 146. The aircraft, which often is used to transport Britain’s royal family, was on a training flight when the incident occurred.

Bart J. Crotty Aviation Consultant

On Nov. 6, 1997, the crew of a U.K. error.1 The report said that magnetic (RAF) 32 Squadron chip-detector plugs (MCDPs) had British Aerospace BAe 146 saw been installed without oil seals indications of significant oil deple- (O-rings) in all four engines of the tion in all four engines. Subsequent BAe 146. low-oil-pressure indications prompt- ed the crew to immediately shut “The aircraft had an experienced down one engine and later to shut crew on board and was close to a down another engine during an suitable airfield when the incident emergency landing at occurred,” the report said. “The crew Stansted Airport. reacted quickly, and the aircraft was landed safely at Stansted. Had the The U.K. Ministry of Defence, in its circumstances not been so fortuitous, incident-inquiry report, said that the the incident may have had graver incident was caused by maintenance consequences.” The BAe 146 incident was similar to transport members of the royal family an event on May 5, 1983, involving and government officials. Although an Eastern Air Lines Lockheed the aircraft are operated by the mili- L-1011. The three-engine jet transport tary, they are maintained according to was en route from Miami, Florida, civilian maintenance programs, doc- U.S., to Nassau, Bahamas, when the umentation, procedures and standards. no. 2 engine low-oil light illuminated. The crew shut down the engine and In its contract proposal to the RAF, diverted the flight to Miami. The FRA said that the night-shift no. 1 engine low-oil light and the maintenance staff would comprise no. 3 engine low-oil light then illumi- 12 workers: one chargehand (gener- nated, and both engines later flamed al foreman), two senior leading hands out. The crew was able to restart the (senior supervisors), three leading no. 2 engine and conduct a successful hands (supervisors) and six fitters single-engine landing in Miami. No (technicians). The company, however, one was hurt, but the event was classi- had a personnel shortage. When the fied as an accident because all three maintenance was performed on the engines required replacement. The incident aircraft, the night shift com- U.S. National Transportation Safety prised nine workers; the staff did not Board (NTSB) said, in its final report include the two senior supervisors on the accident, that oil seals had and one of the three supervisors. been omitted from the MCDPs during maintenance on the engines.2 The The general foreman told one of the report said that the mechanics who supervisors on duty to draw spectro- worked on the engines did not follow metric oil-analysis program (SOAP) procedures for installing the MCDPs samples and to change the MCDPs and that supervisory personnel failed in all four engines. This is a routine to require the mechanics to follow the BAe 146 maintenance procedure that installation procedures. is conducted every 50 engine cycles or 50 flight hours, whichever occurs The report on the BAe 146 incident sooner. said that FRA SERCo, a civilian main- tenance contractor at RAF air The supervisor was a former military- base, performed routine maintenance airframe technician who had received on the aircraft’s Textron Lycoming no engine-maintenance training. Nev- (now AlliedSignal) ALF502 turbofan ertheless, he was authorized by the engines two nights before the incident. company to perform some engine work.

The aircraft was one of three BAe 146s The supervisor searched for MCDP based at RAF Northolt and used to change kits in the maintenance hangar,

2 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 but found none. MCDP change kits — tanks within 15 minutes of engine shut- which include oil plugs, plug seals and down, that MCDPs must be installed SOAP sample bottles — normally were with new seals and that the engines then assembled by technicians who worked must be operated to check for oil leaks in the company’s engine bay. Because and satisfactory engine operation. The of the personnel shortage, however, supervisor did not comply with these the engine-bay night shift had been requirements. eliminated. The engine-bay day shift assembled change kits upon request. “He was not conscious of checking the plugs for seals prior to fitting them “The engine bay [day-shift staff] had to the engines,” said the report. “[The not been advised of the requirement supervisor said that he] was unaware for an MCDP change, and there were of the existence of the AMM proce- no prepared kits available,” said the dure and confirmed that engine ground report. runs were not carried out. … [He] took the SOAP samples from the MCDP The supervisor consulted with the gen- housings, not the engine oil tanks. eral foreman and then went to the en- The engines had not been run in the gine bay to assemble kits from items 15 minutes prior to the [SOAP] sam- available there. The supervisor found ples being collected.” MCDPs in an area of the engine bay that he believed contained BAe 146 The report said that FRA SERCo nor- engine parts that were ready for use. mally did not conduct engine ground The area, however, contained MCDPs runs after MCDP changes. that had been cleaned but had not been inspected or fitted with seals. The “The terms ‘historical’ and ‘common supervisor assembled four change kits practice’ [were] used to explain the with MCDPs from this area. reason for tasks not being carried out [in compliance with] the AMM,” said When the supervisor returned to the the report. “This undermines engi- hangar, he found that none of the neering standards and perpetuates bad technicians was available to obtain the practice.” SOAP samples and install the MCDPs. The supervisor elected to do the work The job card required that the work himself. be signed off by the person who performed the work and by the per- The supervisor did not consult the son who supervised the work. The aircraft maintenance manual (AMM), supervisor asked a technician to sign which said that SOAP samples the job card as the person who per- must be obtained from the engine oil formed the work, and the supervisor

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 3 signed the job card as the person who The crew conducted an instrument supervised the work. landing system approach to Stansted with the thrust levers for the no. 2 “There was, therefore, no supervision engine and the no. 4 engine at flight of the SOAP samples and MCDP idle, and the thrust lever for the no. 1 change,” said the report. engine at maximum thrust. When the crew was sure that the aircraft was Before the incident flight, the aircraft in position for a safe landing, they crew chief confirmed that each engine shut down the no. 2 engine. They shut contained at least three-fourths of down the no. 4 engine during the its total oil capacity of 12.1 quarts landing roll and taxied clear of the (11.5 liters). Ground crewmembers runway using the no. 1 engine. saw no oil leaks and noticed no en- gine abnormalities when the engines The captain watched as the crew were started and when the airplane chief checked the engines. The en- taxied to the runway. gine cowls were covered with oil, and oil spilled to the ground when The airplane departed RAF Northolt the cowls were opened. The MCDPs at 1510 local time. Fifteen minutes were removed and found to have no later, while climbing at about 5,000 seals. feet in instrument meteorological conditions, the crew saw that the Maintenance Errors oil-quantity gauges for the no. 2 Analyzed engine, no. 3 engine and no. 4 engine indicated empty, and that the oil- An analysis of the Ministry of De- quantity gauge for the no. 1 engine fence incident-inquiry report suggests indicated less than one-fourth full. events and factors that could have in- fluenced the events that led to the The crew began flying the airplane depletion of engine oil and to the back to RAF Northolt. The low-oil- emergency landing of the aircraft. pressure warning light for the no. 3 The codes appearing in parentheses, engine then illuminated. At 1527, the in order of priority assigned by the crew shut down the engine, declared author, are explained in Table 1. an emergency and requested — and received — immediate clearance to ¥ Half of the normal complement land at Stansted. of supervisory personnel was available on the night shift. De- The low-oil-pressure lights for the spite the reduction in supervisory no. 2 engine and the no. 4 engine then resources, the general foreman began to illuminate intermittently. did not reduce the amount of

4 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 Table 1 Factors and Elements Involved in Individual and Organizational Maintenance Error

Code Factor Related Elements C Communications Verbal, written, visual, direct, indirect, flight crew, work assignment, shift turnover, etc. D Design Original, modification, STCs, SBs E Environment Weather, lighting, indoor/outdoor temperature, noise G General maintenance Organization or company policies, procedures, manual, AMO rules, requirements, issued authorizations and approvals H Hardware Equipment, tools, parts, materials, GSE, etc. I Inspection Preliminary, progressive, final, NDI, duplicate L Limitations Weight, reach, sight, access M Manufacturer manuals, data Maintenance and service, NDI, SBs, AFM, MEL, SRM, IPC, LLP O Organizational structure, Division of or shared responsibility, support top management resources, quality/safety commitment, planning P Paperwork, record systems Technical logbooks, forms/job cards, records, documents, etc. Q Quality management/audit AMO/AOC formal programs, requirements, effectiveness R Regulations Airworthiness design, maintenance organization, personnel, programs, ADs, AMO/AOC, health/environment, workplace safety S Supervision and Work assignment, oversight, middle management major decision making T Training Basic skills, product technical, special program requirements, initial, recurrent, records W Worker Aircraft maintenance, ground support, fueling, technical administration staff, licensed, unlicensed, line, hangar, shop X Physiological, psychological Stress, fatigue, drugs, alcohol, mental illness ADs = Airworthiness directives AFM = Aircraft flight manual AOC = Air operator certificate AMO = Aircraft maintenance organization GSE = Ground support equipment IPC = Illustrated parts catalog LLP = Life-limited parts MEL = Minimum equipment list NDI = Nondestructive inspection SBs = Service bulletins SRM = Structural repair manual STCs = Supplemental type certificates

Source: Bart J. Crotty

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 5 maintenance work planned or ¥ Ground operation of the engines expected that night (O, S); was not conducted after the maintenance was performed (M, ¥ The elimination of the engine- T, R); and, bay night shift was not planned adequately by management. The ¥ The general foreman did not inadequate planning resulted in adequately monitor the work the unavailability of serviceable performed by the night-shift MCDP kits for the maintenance- personnel and did not ensure hangar night shift (O, S); that their work was performed according to safety standards ¥ Despite the risks involved in per- (C, O, S, R).♦ forming identical maintenance on all aircraft powerplants, MCDP References changes were scheduled to be con- ducted simultaneously on all four 1. U.K. Ministry of Defence. Con- of the BAe 146 engines (C, Q, S); clusions of the Inquiry. A special report prepared for the station ¥ The supervisor exceeded his commander, Royal Air Force capability and experience, and (RAF) Northolt, regarding the exercised poor judgment in incident involving RAF 32 attempting to assemble service- Squadron British Aerospace able MCDP kits from items BAe 146, Nov. 6, 1997. obtained in the engine bay (S, W, M, T); 2. U.S. National Transportation Safety Board. Aircraft Accident ¥ The supervisor had not been Report: Eastern Air Lines, Inc., trained to perform the routine Lockheed L-1011, N334EA, Mi- engine-maintenance task and per- ami International Airport, Mi- formed the task without consult- ami, Florida, May 5, 1983. ing the AMM (S, W, T, M, R); NTSB/AAR-84/04. March 9, 1984. ¥ The supervisor did not comply with AMM procedures (O, S, M, R); About the Author ¥ The supervisor asked a techni- Bart J. Crotty is an airworthiness, cian to sign for work that the maintenance and safety consultant. technician had not performed. He is a former U.S. Federal Aviation The supervisor performed the Administration (FAA) airworthiness work, but he signed as having inspector and trainer, and designated supervised the work (R, P); airworthiness representative. Crotty

6 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 has worked for repair stations, air- half of that period in non-U.S. loca- lines, an aircraft manufacturer, law tions. He has an FAA airframe and firms, consulting firms, safety orga- powerplant mechanic certificate and nizations and several non-U.S. na- a bachelor of science degree in aero- tional civil aviation authorities. His nautical engineering. Crotty resides career spans 39 years, approximately in Springfield, Virginia, U.S.

MAINTENANCE ALERTS

NTSB Recommends The recommended interim actions Actions to Prevent include: Cracked Cases in ¥ Requiring P&W to identify all JT8D Engines JT8D-1 through -17AR and JT8D-200 engine CCOCs that The U.S. National Transportation had boss welds reworked during Safety Board (NTSB) cited a Mc- manufacture, requiring repetitive Donnell Douglas MD-88 in-flight on-wing inspections of the affect- engine failure in recommending ac- ed CCOCs for boss weld cracks, tions to prevent cracking of the com- and, if cracks are found, requir- bustion chamber outer case (CCOC) ing replacement of the CCOC; of certain Pratt & Whitney (P&W) ¥ Requiring JT8D engine CCOCs JT8D engines. that did not have boss welds re- worked during manufacture to NTSB recommended that the U.S. undergo repetitive on-wing in- Federal Aviation Administration spections for cracks in the welds (FAA) require that all P&W JT8D-1 and, if cracks are found, requiring through -17AR and JT8D-200 en- replacement of the CCOC; and, gines have a one-piece integral-boss CCOC installed “at the next shop visit ¥ Requiring one-time inspections to [in which] the engine’s CCOC be- identify any P&W JT8D-1 through comes accessible.” -17AR and JT8D-200 COCCs with magnetic bosses and, if NTSB also recommended that FAA such bosses are found, requiring take several interim actions, noting replacement of the CCOC with a that so many of the engines are in one-piece, integral boss CCOC. service that it will take several years for all of them to be retrofitted with The incident cited by NTSB in issu- the one-piece integral-boss CCOC. ing its recommendations involved

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 7 an Oct. 15, 1998, Delta Air Lines flight but the JT8D-1 through -17AR en- that experienced an uncontained fail- gines, with similar CCOCs, have had ure of the no. 2 (right) engine im- at least 10 CCOC ruptures that initi- mediately after takeoff from Logan ated from boss welds and at least nine International Airport in Boston, Mas- from rear-flange-bolt holes, NTSB sachusetts, U.S. The pilots declared an said. Because of past ruptures and emergency and returned to Boston. cracking, and in response to NTSB recommendations, FAA has issued a Examination of the engine “revealed series of airworthiness directives that the rear sections of the upper and involving the CCOC bosses. lower forward cowl doors were deflect- ed away from the engine and that the Engine Fire Prompts rear cowl doors were missing,” NTSB said. “Subsequent disassembly of the NTSB Call for Changes engine revealed [that] the … CCOC In Fire-detection Systems had ruptured axially from the fuel drain The U.S. National Transportation boss at the bottom of the case.” Safety Board (NTSB) has recom- mended modifications of the engine As a result of the incident, Delta in- and auxiliary power unit (APU) fire- spected JT8D-200 engines with detection systems in the Airbus CCOCs similar to the one that ruptured. A300-600 and A310 airplanes in the The inspections identified 12 more wake of an in-flight engine fire last CCOCs with cracks in and around the year on an American Airlines flight boss welds, but Delta said that there from San Juan, Puerto Rico, U.S. was no visual evidence of mechanical thinning adjacent to the cracks, as was NTSB asked the U.S. Federal Avia- found on the ruptured CCOC. tion Administration (FAA) to issue an airworthiness directive (AD) calling In March 1999, P&W issued an alert for changes in fire-detection systems service bulletin calling for an initial and flight-crew procedures for deal- on-wing inspection procedure for ing with in-flight engine fires. CCOC fuel-drain boss-weld cracks. Nearly two months later, the compa- The recommendation followed inves- ny said that it had received no reports tigations of the fire in the no. 1 en- from JT8D-200 operators of CCOC gine of an American Airlines Airbus inspections accomplished in accor- A300B4-605R shortly after takeoff dance with the bulletin. from San Juan on July 9, 1998. The flight crew declared an emergency, The CCOC rupture on the Delta flight followed in-flight engine-fire proce- was the first in a JT8D-200 engine, dures and returned to San Juan, where

8 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 the fire was extinguished and emer- incident raises broader concerns about gency procedures were used to evac- the A300-600 and A310 fire-detection uate passengers and crewmembers systems and in-flight engine-fire- from the aircraft. Twenty-eight pas- emergency procedures that … FAA sengers received minor injuries dur- should also take action to address.” ing the evacuation; the other 224 occupants were not injured. NTSB asked that FAA issue an AD to require operators of A300-600 and Examination of the aircraft showed A310 airplanes to modify engine and that the fire had damaged the no. 1 APU fire-detection systems so that, in engine’s fan cowls, thrust reverser, case of a single-loop fault in the engines core cowls, the engine core compart- or APU, the remaining loop would au- ment outside the engine cases and the tomatically be armed for fire detection. fire-detection systems. Damage to the airframe was minimal. NTSB also called for issuance of a flight standards information bulletin The investigation found that the flight that would require principal opera- crew received the engine-fire warn- tions inspectors to emphasize that ing shortly after takeoff. In response, flight crews should deactivate the they immediately retarded the no. 1 faulted fire-detection loop if a fire engine throttle, and after 88 seconds, warning on an engine or APU chang- the fire warning ceased. es to a loop fault. For operators of “The flight crew subsequently select- aircraft not modified to automatical- ed the no. 1 engine’s fuel lever to ‘off’ ly arm the remaining loop for fire and discontinued the engine-fire pro- detection in case of a loop fault, the cedures without discharging the fire- inspectors also should emphasize extinguishing bottles,” NTSB said. proper methods of identifying a failed “During the airplane’s final approach, fire-detection loop, NTSB said. the flight crew was unaware that the engine was still on fire until alerted by NTSB said that Airbus should be re- the flight attendants. After landing, the quired to include supplementary flight crew discharged the fire bottles.” information in the in-flight engine- fire procedure outlined in flight-crew NTSB said that it supports actions operating manuals for the A300-600 taken by General Electric Aircraft and the A310 to indicate an appro- Engines, which manufactured the air- priate amount of time that flight craft’s CF6-80C2A5 engines, and crews should wait after the throttle FAA to address the cause of the en- is retarded to idle before the fuel gine fire. But, the agency said, “This lever is selected to “off.”♦

FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 9 NEWS & TIPS

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The two-speed electric pump weighs 53 pounds (24 kilograms) and oper- Enerpac ates on standard 50/60 Hz power. Portable Pump Features include an adjustable pres- sure-relief valve for accurate torque Double-duty Tape adjustment and an internal pressure- Withstands Heavy Use relief valve to prevent overpressuriza- tion. The unit is available with a heat Plasma Flame Spray Tapes from C.S. exchanger and comes with a standard Hyde Co. withstand heavy-duty grit remote control. blasting and protect from overspray- ing and intense heat and abrasion, The air-driven model features a high- said the manufacturer. The two-ply/ output, air-driven, two-stage pump double-duty tapes eliminate the need and an air-operated valve with remote for a second taping operation when control. The model is suitable for multiple layers are required. use under circumstances that require explosion-proof equipment, said the A high-temperature silicone adhesive manufacturer. provides heat resistance, high

10 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 noise while maximizing the wearer’s ability to hear useful sounds such as speech, said the manufacturer.

Hearing protectors now available in- clude two over-the-head earmuff models and one cap-mounted earmuff model. The earmuffs do not need to be removed for wearers to understand speech in a noisy environment, said the manufacturer.

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FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 11 International Civil Aviation Organi- For more information: CSSINFO, zation Annex 1 amendment no. 161. 310 Miller Ave., Ann Arbor, MI The amendment requires all licensed 48103 U.S. Telephone: +1(734) 930- engineers to have knowledge of “hu- 9277. Web site: www.cssinfo.com. man performance and limitations rel- evant to the duties of an aircraft An Endorsement of maintenance holder,” said IFA. Red Tape

The program comprises 11 elements, A report in the March-April issue of including four videotapes, briefing Aviation Mechanics Bulletin on the use and training materials, cases histories of brightly colored tape to cover the al- and human factors study materials. ternate static port during a leak test of a helicopter’s pitot-static system prompt- The program was produced by TVC ed a related suggestion from a reader. Television Communications. The pro- gram costs US$5,500.00; IFA mem- Charles Lester of IBM Flight Opera- bers receive a 10 percent discount. tions in White Plains, N.Y., U.S., said that he began using colored tape af- For more information: Julian Dinsell, ter he visited a general aviation shop Managing Director, TVC Television that had put the product to good use. Communications, 15 Greek Street, London WIV 5LF. Telephone +44 “They were using brightly colored 171 734 6840. surveyor’s tape to mark work that was incomplete or presented some hazard of being forgotten,” Lester wrote. Firm Opens Online “The tape is available in any hardware Technical Bookstore store and costs next to nothing. It can be tied or taped in place. The surface CCSINFO has opened an online is made to be written on, so notes can technical bookstore offering pub- be left on it. If something needs to be lications on nearly 500 subjects, marked inside an aircraft, a piece can including aerospace and aeronautical be made long enough to hang outside engineering. the area so anyone walking by will notice it. Every one of our mechan- Books and industry standards can be ics has a roll of it. ordered online, and a number of stan- dards can be downloaded instantly. “We have been using this with great Users can conduct a single search success for several years now and have to find both technical books and prevented numerous situations that industry standards. could have compromised safety.”♦

12 FLIGHT SAFETY FOUNDATION ¥ AVIATION MECHANICS BULLETIN ¥ JULYÐAUGUST 1999 BLANK INSIDE BACK COVER deRIO Janeiro,Brazil November 8–11, 1999 Enhancing Safety in the 21st Century

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