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B734, en-route, Daventry UK, 1995

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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.
Event Details
When February 1995
Actual or Potential
Event Type
AW, HF, LOC
Day/Night Day
Flight Conditions VMC
Flight Details
Aircraft BOEING 737-400
Operator British Midland
Domicile United Kingdom
Type of Flight Public Transport (Passenger)
Origin East Midlands Airport
Intended Destination Lanzarote
Actual Destination London Luton Airport
Take off Commenced Yes
Flight Airborne Yes
Flight Completed Yes
Flight Phase Climb
ICL / ENR
Location En-Route
Origin East Midlands Airport
Destination Lanzarote
Location
Approx. near Daventry, UK
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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
Injuries "None" is not in the list of possible values (Few occupants, Many occupants, Most or all occupants) for this property.
Fatalities "None" is not in the list of possible values (Few occupants, Many occupants, Most or all occupants) for this property. ()
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 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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).