B734, en-route, Daventry UK, 1995
B734, en-route, Daventry UK, 1995
Summary
On 23 February 1995, a British Midland Boeing 737-400 made an emergency landing at Luton airport UK after losing most of the oil from both engines during initial climb out from East Midlands airport UK, attributed to failures in the quality of maintenance work and procedures during routine inspections of both engines prior to the flight.
Flight Details
Aircraft
Operator
Type of Flight
Public Transport (Passenger)
Flight Origin
Intended Destination
Actual Destination
Take-off Commenced
Yes
Flight Airborne
Yes
Flight Completed
Yes
Phase of Flight
Climb
Location
Approx.
near Daventry, UK
General
Tag(s)
Inadequate Airworthiness Procedures,
Ineffective Regulatory Oversight
HF
Tag(s)
Violation
LOC
Tag(s)
Loss of Engine Power
EPR
Tag(s)
MAYDAY declaration
AW
System(s)
Engine - General
Contributor(s)
Maintenance Error (valid guidance available)
Outcome
Damage or injury
Yes
Aircraft damage
Minor
Non-aircraft damage
Yes
Non-occupant Casualties
No
Occupant Injuries
None
Occupant Fatalities
None
Off Airport Landing
Yes
Ditching
Yes
Causal Factor Group(s)
Group(s)
Aircraft Technical
Safety Recommendation(s)
Group(s)
None Made
Investigation Type
Type
Independent
Description
On 23 February 1995, a British Midland Boeing 737-400 made an emergency landing at Luton airport UK after losing most of the oil from both engines during initial climb out from East Midlands airport UK, attributed to failures in the quality of maintenance work and procedures during routine inspections of both engines prior to the flight.
Synopsis
This is an extract from the report published by the Aircraft Accident Investigation Branch (UK) (AAIB), UK:
"The incident occurred when the aircraft was climbing to cruise altitude after a departure from East Midlands Airport en-route to Lanzarote…Following indicated loss of oil quantity and subsequently oil pressure on both engines, the crew diverted to Luton Airport; both engines were shut down during the landing roll. The aircraft had been subject to boroscope Inspections on both engines during the night prior to the incident flight. The High Pressure (HP) rotor drive covers, one on each engine, had not been refitted, resulting in the loss of almost all of the oil from both engines during flight. There were no injuries to any crew or passengers…
The investigation identified the following causal factors:
- The aircraft was presented for service following Borescope Inspections of both engines which had been signed off as complete in the Aircraft Technical Log although the HP rotor drive covers had not been refitted.
- During the Borescope Inspections, compliance with the requirements of the Aircraft maintenance manual was not achieved in a number of areas, most importantly the HP rotor drive covers were not refitted and ground idle engine runs were not conducted after the inspections.
- The Operator's Quality Assurance Department had not identified the non-procedural conduct of the Borescope Inspections prevalent amongst Company engineers over a significant period of time.
- The Civil Aviation Authority, during their reviews of the Company procedures' for JAR-145 approval, had detected limitations in some aspects of the Operator's Quality Assurance system, including procedural monitoring, but had not withheld that approval, being satisfied that those limitations were being addressed."
Related Articles
General
AW
LOC
Further Reading
For further information see the full Report including Appendices published by the AAIB (UK).
