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.

Event Details
When	February 1995
Actual or Potential Event Type	Airworthiness, Human Factors, Loss of Control
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"None" is not in the list (Few occupants, Many occupants, Most or all occupants) of allowed values for the "Injuries" property.
Fatalities	None"None" is not in the list (Few occupants, Many occupants, Most or all occupants) of allowed values for the "Fatalities" 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 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:

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

• Base Maintenance
• Maintenance Error Management System

AW

• Airworthiness

LOC

• Loss of Control,

Further Reading

For further information see the full Report including Appendices published by the AAIB (UK).