In-Flight Loss of Engine Power Eastern Airline - Case Study Example

TABLE OF CONTENTS 1. Executive summary Flight 855 of the Eastern Air Lines, Inc., a Lockheed L-1011, N334EA, left Miami International Airport for Nassau, Bahamas on May 5, 1983 at 0856; onboard were 172 persons who comprised of 10 crewmembers and 162 passengers. When the plane was going down through 15,000 feet at about 0915:15, the oil pressure for the engine number 2 lighted up. The captain had to return to Miami to land after shutting up the affected engine. After clearance, the airplane was on its way to Miami and was climbing FL 200. The low oil pressure indicator lights for engines numbers 1 and 3 lighted up as the plane took off. At 0928:20, the airplane was at 16,000 feet when the No. 3 engine blazed. The No. 1 engine flamed out at 0933:20, when the flight crew was restarting the No. 2 engine. From approximately 13,000 feet to about 4,000 feet the airplane descended without power, and in a short while after this attitude the No. 2 engine began to operate. At Miami International Airport the airplane landed using one-engine at exactly 09:46, and none of the occupants was injured. The feeling of the National Transportation Safety Board is that the accident was caused by the missing O-ring seats for the master chip detector assemblies, lack of lubrication and thus the three engines of the airplane were not in good working condition. The mechanics were unable to pursue and the well-known and appropriate procedures for fixing the master chip detectors in the engine lubrication system. The supervisor also failed to ensure that the mechanics complied with the approved fixing procedures of the O-rings. The management of the Eastern Air Lines also failed on its part as they were unable to sufficiently assess past similar occurrences and to take appropriate action of correcting the mistakes (Barnes, 2003). The contribution of the Federal Aviation Administration maintenance inspectors to the accident was their failure to look closely at the incidents related to the master chip detectors and apply effective maintenance strategies to any occurrence of such an incident. 2. Factual information of the flight 2.1 history of the flight Eastern Air Lines, Inc., Flight 855, a Lockheed L-1011, N334EA, on May 5, 1983, was a scheduled flight for passengers from Miami, Florida, to Nassau, New Providence Island, Bahamas. The flight crew came earlier at the airport and performed the necessary activities prior to the scheduled takeoff time. The weather forecast report indicated that there would be scattered rain showers at Nassau at the arrival time. At 0900, Nassau weather was partly: 500 feet scattered, 1,000 feet broken, 7,000 feet overcast, 4 miles visibility, and light rain and fog. There was a delay of the frontal system to the north-northeast from southern Florida and the Florida Keys. At 0900, Miami International Airport weather conditions were: ceiling 2,300 feet broken, and visibility of 7 miles. The flight engineer who carried out a “walk-around" inspection noted that the engines were in good working conditions, and the entire engine instrument was perfect. At 08:56, Flight 855 comprising of 162 passengers and 10 flight crew took off from 27R at Miami International Airport. The flight was estimated to take 37 minutes. The captain and the crew team commented that the initial climb takeoff to Flight Level (FL) 230 was okay. The flight engineer asserted that he had checked what the captain had done during takeoff and had he scanned the panel of the flight engineer for strange readings. When the plane had gone 1,000 feet, the flight engineer synchronized the cabin pressure and the cabin cooling system. The flight engineer indicated that he had examined the engine instruments, and called the Eastern Air Lines at Miami to relay information that the airplane had left, when the airplane passed through 1,500 feet. He also went on to check the engine instruments again to ensure that everything was ok. The flight engineer said that from the time the plane took off until when it was at FL 230 there was no decline in the oil quantity gauges and the three indicators showed approximately 18 quarts (full indication is 21 quarts). At around 0908:14, Flight 855 reached FL 230. And at 0910, the flight was ready to go down to 9,000 feet, which the captain did. At 0911:17, Nassau approach control was contacted by the flight engineer who reported that the plane was flying through FL 200, 70 miles from Nassau. Nassau approach control reported the weather at the upper limit was 1,000 feet broken and visibility was 5 miles, upper limits to the east and south were 500 to 800 feet, and thunderstorms in the north. Flight 855 was informed by Nassau approach control that it was approximately 30 miles behind a light twin-engine airplane (Barnes, 2003). When Flight 855 went down through 15,000 feet, the flight engineer was informed by the captain said that the low oil pressure caution indicator light for No. 2 engine showed a light indication. The flight engineer made a call on where the airplane had reached and prepared the landing card after confirming the amount of oil and pressure gage readings of approximately 15 quarts for Nos. 1 and 3 with satisfactory oil pressure range. The No. 2 engine was reading 8 quarts, with pressure that fluctuated between 15 psi and 25 psi. This did not draw his concern since expected fluctuations were to a minimum of 3 quarts on both sides of 18 quarts, but he established that the L-1011 had never experienced an oil pressure problem. The flight engineer informed the captain that they were in danger because the minimum oil pressure required on the No. 2 engine was 30 psi but at that moment it was fluctuating between 15 and 25 psi and the oil gauge reading was 8 quarts while Nos. 1 and 3 engines read approximatelly15 quarts (James & Robert, 2000). The No. 2 engine was put off, the captain put on the auxiliary power unit (APU). At 0915:26, when the plane had raised 12,300 feet, the captain made a request to return to Miami; which was accepted by the check captain. When the airplane was approximately 50 miles from Nassau, the captain asserted that it was descending due to the deteriorating weather conditions. The captain also felt that they could experience some landing delays at Nassau caused by the non-radar environment and other aircrafts using the same runaway. At 0915:48, Flight 855 was allowed to make 1800 turn while maintaining the 12,000 feet. Miami Air Route Traffic Control Center (ARTCC) was contacted by Flight 855 at 0918:11, and at 0918:36, the flight was allowed to rise to FL 200. At this juncture the flight engineer was done with the examination of engine shutdown and the secondary the emergency checklist without paying attention to the Nos. 1 and 3 indicators since he assumed that approximately 4 minutes were required to accomplish these tasks. The low oil pressure light indicator for the No. 3 and No. 1 engines respectively illuminated while the oil quantity gauges were reading zero for all three engines, when the airplane was rising through 15,000 feet. Miami ARTCC was informed about the engine gauge readings at 0923:15, when the airplane level was at 16,000 feet when they confirmed that the indicators were not working because it was impossible for the three engines to have zero oil pressure and quantity. Miami Eastern Air Lines maintenance staff was contacted by the flight engineer to verify if a faulty universal source of electrical source could have its effects spread to the engine instruments. Miami Technical Center replied Flight 855 saying the No. 2 AC bus was the universal power source for the oil quantity instruments”. At 0928:20, there was failure of No. 3 engine, the airplane gradually started to descent, when it was approximately 80 miles from Miami; the flight crew discovered that the zero oil pressure and quantity indications were correct. At 0929:15, Miami ARTCC allowed Flight 855 to go down to any height and direct to Miami International Airport and land on runway 27L. The flight crew tried to start the No. 2 engine which was unsuccessful; and at 0933:20, No. 1 engine went off when the airplane was approximately 12,000 feet over the ocean. The descending rate of the plane was approximately 600 feet per minute (fpm) with one engine on, the rate augmented to approximately 1,600 fpm with no engine operating. The airspeed indicated a constant of approximately 225 knots all through the descent. After all engines ceased operating hydraulic pressure and electrical power of the airplane was got from the APU which enabled the flight crew to carry out all their operation on the airplane (Gilfford, 2005). At 09: 33 to 38, Flight 855 informed the Miami ARTCC about failure of the engines when the airplane was approximately 55 miles from Miami. After a while, the flight engineer made an announcement about the ditching that was forth coming. The senior flight attendant advised the passengers to support themselves since he felt that the airplane was entering the water. At this moment the Miami ARTCC notified the Coast Guard District Headquarters at 0928:18. Immediately A Coast Guard Falcon jet and a helicopter left the Coast Guard station at Opa Locka, Florida. A helicopter and a C-130 airplane were ready for the flight from USCG Station Air, Clearwater, Florida at 0936 but were redirected to give a hand to Flight 855. More alerts were given to three Coast Guard helicopters and a Falcon jet and were ready to react to the tragedy. As standby vessels there was one Coast Guard cutter plus five other patrol vessels at sea. Air Force C-130 and a helicopter, from Homestead Air Force Base, was informed and were ready to takeoff. An alert was given to all aircraft and land machines were alerted and by 0944 they were ready for takeoff. The captain gave a second try to put on the No. 2 engine but was futile. He then tried to simultaneously start the No. 3 and No.1 engines, but was still futile while the flight crew were analyzing the ditching checklist. The captain made a third attempt of starting the No. 2 engine which restarted at 0938:18, 4,000 feet and airspeed of approximately 250 knots and approximately 22 miles from Miami. When the airplane was approximately 3,000 feet it stopped descending, and gradually started to ascend to 3,900 at 0940:20 and leveled then started the final dive for landing at Miami International Airport at 0943. The airplane landed at Miami at 0946. 2.2 Injuries to Persons Injuries Crew Passenger others fatal 0 0 0 Serious 0 0 0 Minor 0 0 0 None 10 162 0 Total 10 162 0 (James & Robert, 2000). 2.3 Damage to aircraft There was a considerable harm to Nos. 1 and 3 engines with minor damages on the No. 2 engine. After careful engine inspection it was seen that the O-ring seals were omitted in the installation of the master chip detectors on each engine which allowed oil leakages (Williams & Steven, 2004). 2.4 Personnel information With regard to the current system the flight attendants were competent. 2.5 Aircraft Engine Failure and history The damage that occurred to the three engines was due to inadequate oil lubrication and the constant engine use. The insufficient engine oil lubrication was caused by to the absence O-ring seals in the joints of the master chip detector magnetic probes which resulted to oil leakage. The bearing lost the normal axial operational location due to overheating and the gear teeth of the gear shaft of the radial bevel could not mesh with the high pressure compressor bevel gear teeth. The disengagement of gear teeth detached the drive to the engine fuel pump, thus cutting off fuel flow and the engines operation stopped due to the flame out (Gilfford, 2005). 2.6 Component of failure history 2.6.1 Number 3 Engine The interior housing of low pressure bearing seal ring, fore and back of the hydraulic seal fin and where the seal ring rests, the low pressure bearing assembly, and the interior of the intermediate-pressure compressor rear stub shaft and the fore of the oil reservoir, were coated with a tacky oil film. The transitional pressure bearing assembly was dry, heavily burnt, and discolored. Most of the ball bearing were compressed but with their spherical shape and heavily discolored. The high pressure ball bearings were heavily burnt discolored. The shape of most of the ball bearings was not affected. All the balls had different sliding degrees and rotating flats. The internal gearbox driven gear shaft, located in the interior gearbox assembly of the intermediate module made a radial outward move making contact with the oil trough. The baffle was broken on one side. All driven gear shaft teeth were in good order. The external tips of the gear teeth were smeared heavily, and the gear and the ball bearing were held, the ball bearings were discolored heavily. The bearing balls had flats, and the cage broke. The interior and exterior roller bearings for the inner gearbox driven bevel gear were discolored heavily. All the rollers were flattened. The high pressure compressor that drives bevel gear of module 4 was locked because of the seizure of the high pressure bearing. The teeth of the gear were okay but with a heavy smear on the outer tips. The high pressure bearing and the radial ball bearings of the driven gears, the driving and driven gears location was lost hence they made an outward move which caused the engine to stop, this was because the gears were unable to mesh and the fuel pump was disengaged from the drive. 2.6.2 Number 1 Engine The interior part of the housing for the low pressure bearing ring seal, the internal walls of the transitional pressure compressor back stub shaft, and the front of the oil weir, were coated with a film of degraded oil. The intermediate pressure bearing assembly was dry in the outside and produced noise when rotated. The interior parts of the bearing were dry and discolored. The inner, outer races and the high pressure ball bearings were dry, severely overheated and discolored. Most balls were disfigured making them unable to slide and rotate. The interior gearbox driven gear shaft made an outward radial move making rotational contact with the oil baffle which led to engine shutdown due to lack of the fuel pump drive. Other parts of the internal gearbox assembly showed similar conditions in the No. 3 engine, but the oil baffle was okay. Housing assembly ball bearing cage for radial drive driven bevel gear, and the interior and exterior roller bearing roller were okay. 2.6.3 Number 2 Engine The drive bevel and driven gears of the interior gearbox assembly had a normal engagement and a free rotation but the ball bearings were discolored. 2.7 Meteorological information The area weather forecast as per National Severe Storms Forecast Center for a third of southern Florida and coastal waters were valid until 1700, May 5, 1983. Cloud cover was 4,000 feet scattered, 8,000 feet broken to overcast, likelihood of light rain showers. After 0800 to 1000, 1,000 feet scattered and ceiling 15,000 feet. 0730 radar overlay report from the National Weather Service (NWS) Miami weather radar indicated little reasonable showers in Florida, north, and west of the Bahamas Islands. The height precipitation was recorded as 19,000 feet west of the Bahamas Islands at 0830 (Key & Benjamin, 2007). Nassau surface weather observations (James & Robert, 2000). Miami International Airport surface weather observations Time 0850 0943 Cloud cover (agl) Surface aviation; ceiling at 2,300 and broken at 4,500 and 8,000 Local ; ceiling scattered at 2,300 and 4,500 ceiling estimated to be 8,000 Visibility ( miles) 7 7 Wind (Knots) 010o at 8 010o at 7 Altimeter (in inches Mercury[Hg]) 29.94 29,96 Temperature 68oF Dew 55oF 57oF Weather None None Remarks None Aircraft misfortune (James & Robert, 2000). 2.8 Communications Communication was effectual all through the flight. 2.9 Flight Recorders The airplane contained a Lockheed Model 209E digital flight data recorder (DFDR), Serial No. 1150, and a Fairchild A—100 cockpit voice recorder (CVR), serial No. 1553. Which were removed from the airplane and taken for laboratory examination and read out at Safety Board's in Washington, D.C. After the laboratory examination the recorder’s working conditions were okay and the CVR was of good quality. The recorder had only information for after Flight 855 landing at Miami International Airport. The DFDR, which stores information for a span of 25 hours, was okay with good recording medium on all capstans, reels, and guides. The data graphs took a time span of 51-minute which ended w with the landing at Miami International Airport. 2.10 Wreckage and impact information The three engines were damaged and that was the only damage that was experienced. The first on-site examination was inspection of the airplane engines where the engine master chip detector assemblies for the three engines were removed. It was confirmed that the two seal rings (O-rings) were missing from each assembly. The high pressure rotor system of No. 1 engine was unable to rotate. The intermediate and high pressure rotor systems of No. 3 engine were unable to rotate. No. 2 engine was serviced, where it could start and run up to take-off power. 3. Analysis 3.1 General accident Sequence Occurrences of oil Loss as a result of Master Chip Detector or O-ring seal Problem Date Cause Work card 7204 Failure 9-2-81 One Engine Shut Down; “completed Flight” Miami Master chip detector not installed 11-9-81 One engine shut down; impromptu landing. Atlanta O-rings absent 11-11-81 One engine shut down; Unscheduled landing. Miami O-ring seals absent 12-11-81 One engine shut down; unscheduled landing JFK Master chip detector improperly installed 1-14-82 One engine shut down; unscheduled landing JFK O-ring seals absent 1-14-82 No engine shut down; “completed flight,” Atlanta Master chip detector not installed 3-24-82 One engine shut down; completed flight Boston Master chip detector improperly installed 8-19-82 No engine shut down; completed flight Miami Master chip detector missing 10-11-82 No engine shut down; completed flight Miami Leaking O-ring seals l 12-2-82 One engine shut down; unscheduled landing Miami O-ring seals deteriorated 12-14-82 One engine shut down; unscheduled landing Miami Spoiled O-ring seals 3-7-82 No engine shut down; unscheduled landing Miami absent O-ring seals 5-5-83 Three engine shut down; emergency landing Miami missing O-ring seals on all master chip detectors (Brian, 2008) 3.2 Root Cause Component failure Description The damage that occurred to the three engines was due to inadequate oil lubrication and the constant engine use. The insufficient engine oil lubrication was caused by the absence O-ring seals in the joints of the master chip detector magnetic probes thus, oil leakage resulted. The bearing lost the normal axial operational location because the heat damaged the high pressure bearing races and ball bearings in the Nos. 1 and 3 engines, which led to the backward dislodgment of the high pressure compressor rotor assembly. The radial bevel gear shaft teeth could not mesh with the high pressure compressor bevel gear teeth. The disengagement of gear teeth detached the engine drive to the fuel pump, thus cutting off fuel flow and the engines operation stopped due to the fame out. After the accident examination it was hard to seize the bearings before cooling of the engine and solidification of the molten bearings. It was seen that the Nos. 1 and 3 engine bearings were almost melting when the respective flame-outs occurred due to the overheating caused by lack of lubrication. The No. 2 engine was put off in the early emergency, therefore did not fame out. But heat discolored the ball bearings of the radial drive bevel gear and the intermediate interior gearbox assembly the roller bearing. The quantity of oil that remained in the No. 2 engine was less than that in engines Nos. 1 and 3. 4. Findings summary ( probable cause) The view of National Transportation Safety Board is that the occurrence of the catastrophe was due to missing O-ring seals in the detector’s master chip, that led to poor lubrication and hence damage to the three engines. The mechanics were unable to install the master chip detectors. The supervisory personnel repeatedly failed to make sure that the mechanics were following the approved installation procedures. The Eastern Air Lines management was unable to adequately appraise the previous implication of similar occurrences and make appropriate correction. Federal Aviation Administration maintenance inspectors contributed to the accident by failing to examine the implication of the behavior of the master chip detector’s through proper observations and prevent the recurrence of such tragedies (Brian, 2008). 5. Recommendations 5.1 NTSB recommendations 1. Offer FAA air carrier inspectors, in the examination of information on airline failure trends, reported airline maintenance data. FAA should analyze and rank the significance of acquired information to flight safety. (Class II, Priority Action) (A-84-8). Federal Aviation Administration's chief maintenance inspectors must record and occasionally avail reports on the efficiency of FAA. (Class II, Priority Action) (A-84-9) 2. The Eastern Air Lines flight guidebook tragedy landing/ checklist for ditching, and landing procedures for flight deck crew must be revised to ensure that; a) The dealings in the manual for flight attendant where the cockpit crew are supposed to constantly report to the flight attendants about the tragedy. b) A consistent indicator must be recommended to flight attendants to enable passengers support themselves. (Class II, Priority Action) (A-84-17) 3 Aircraft inspectors of operations are required to appraise and modify the flight and flight attendant manuals, and education programs of particular airplanes for smooth operations. Communications done among crewmembers during emergencies should be effective. The cockpit crew should report to the flight attendant concerning the emergency situation and the approximated available time to arrange the cabin and a homogeneous sign to flight attendants to alert passengers to support themselves. (Class II, Priority Action) (A-84-18) 4 Starting of a research and development plan with a goal of reviewing the least standards for life saving found in Technical Standard Order (TSO) Cl3d, which requires that the lifesaving can be implemented within the shortest time by a normal passenger without assistance in a sitting position with the lap belt fastened. (Class II, Priority Action) (A-84-19) 5 14 CFR 121 be revised to allow TSO-Cl3d life vests installation on all passenger aircraft within one year of the effective date of TSO-Cl3d. (Class II, Priority Action) A-84-20). 5.2 SF375 group recommendation Air carrier operations inspectors must carefully examine all the airplane manuals to ensure that all the finer details are addressed before using any airplane. References Barnes, W. (2003). Aircraft accident reconstruction and litigation. New York: Lawyer & Judges publishing Company. Brian, P. (2008). Is It Safe?: Why Flying Commercial Airliners Is Still a Risky Business .. Bloomington: Brian power-Water XIII. Gilfford, F. (2005). The world of hedge funds: characteristics and analysis. Danvers: Stallion Press. James, M., & Robert, L. (2000). Aircraft accident analysis: final reports. New York: McGraw- Hill. Key, D., & Benjamin, A. O. (2007). The limits of expertise: rethinking pilot error and the causes of airline . England: Ashgate Publishing Limited. Williams, C., & Steven, W. (2004). Aircrew security: a practical guide. England: Ashgate Publishing Limited. Read More