Event Details

Title:Loss of oil on climb on both engines, Boeing 737-400, G-OBMM
Micro summary:This Boeing 737-400 lost nearly all the oil in both engines on climb.
Event Time:1995-02-25 at 1205 UTC
File Name:1995-02-25-UK.pdf
Publishing Agency:Aircraft Accident Investigation Board (AAIB)
Publishing Country:United Kingdom
Report number:(EW/C95/2/3)
Diversion Airport:London Luton Airport, London, England
Site of event:Overhead Daventry, Climb
Departure:Nottingham East Midlands Airport, Leicestershire, England
Destination:Lanzarote Airport, Arricife, Canary Islands, Spain
Airplane Type(s):Boeing 737-400
Flight Phase:Climb
Operator(s):BMI British Midland Airways
Type of flight:Revenue
Serious Injuries:0
Other Injuries:0
Diverted to:London Luton Airport, London, England
Executive Summary:The incident occurred when the aircraft was climbing to cruise altitude after a departure from East Midlands Airport en-route for Lanzarote Airport in the Canary Islands. Following an 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 Borescope 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 aircraft was undamaged; both engines were removed and examined as a precautionary measure.

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 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.

Fifteen safety recommendations are made.
Learning Keywords:Operations - Maintenance
Systems - Engine - Contained Engine Failure
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