ASN Aircraft accident Lockheed L-1011 TriStar 1 N334EA Miami International Airport, FL (MIA)

Home » Database » 1983

Status:	Accident investigation report completed and information captured
Date:	Thursday 5 May 1983
Time:	09:46
Type:	Lockheed L-1011 TriStar 1
Operator:	Eastern Air Lines
Registration:	N334EA
MSN:	1141
First flight:	1976
Engines:	3 Rolls-Royce RB211-22B
Crew:	Fatalities: 0 / Occupants: 10
Passengers:	Fatalities: 0 / Occupants: 162
Total:	Fatalities: 0 / Occupants: 172
Aircraft damage:	None
Location:	Miami International Airport, FL (MIA) ( United States of America)
Phase:	En route (ENR)
Nature:	International Scheduled Passenger
Departure airport:	Miami International Airport, FL (MIA/KMIA), United States of America
Destination airport:	Nassau International Airport (NAS/MYNN), Bahamas

Narrative:
At 08:56 Eastern Air Lines Flight 855 departed Miami International Airport en route to Nassau, Bahamas. About 09:15:15, while descending through 15,000 feet, the low oil pressure light on the TriStar's No. 2 engine illuminated. The No. 2 engine was shut down, and the captain decided to return to Miami to land. The airplane was cleared to Miami and began a climb to FL200. While en route to Miami, the low oil pressure lights for engines Nos. 1 and 3 illuminated. At 09:28:20, while at 16,000 feet, the No. 3 engine flamed out. At 09:33:20, the No. 1 engine flamed out while the flightcrew was attempting to restart the No. 2 engine. The airplane descended without power from about 13,000 feet to about 4,000 feet, at which time the No. 2 engine was restarted. The airplane made a one-engine landing at Miami International Airport at 09:46. There were no injuries to the occupants.

Probable Cause:

PROBABLE CAUSE: "The National Transportation Safety Board determines that the probable cause of the accident was the omission of all the O-ring seals on the master chip detector assemblies leading to the loss of lubrication and damage to the airplane's three engines as a result of the failure of mechanics to follow the established and proper procedures for the installation of master chip detectors in the engine lubrication system, the repeated failure of supervisory personnel to require mechanics to comply strictly with the prescribed installation procedures, and the failure of Eastern Air Lines management to assess adequately the significance of similar previous occurrences and to act effectively to institute corrective action.
Contributing to the cause of the accident was the failure of Federal Aviation Administration maintenance inspectors to assess the significance of the incidents involving master chip detectors and to take effective surveillance and enforcement measures to prevent the recurrence of the incidents."

Accident investigation:

Investigating agency:	NTSB
Status:	Investigation completed
Duration:	10 months
Accident number:	NTSB/AAR-84/04
Download report:	Final report

Classification:

Wrong installation of parts
All engine powerloss
Forced landing on runway

Sources:

» NTSB

Follow-up / safety actions

NTSB issued 9 Safety Recommendations

Issued: 29-MAR-1984	To: FAA	A-84-17
REQUIRE THE REVISION OF THE EASTERN AIR LINES FLIGHT MANUAL EMERGENCY LANDING/DITCHING CHECKLIST IN THE EMERGENCY PROCEDURES SECTION AND THE FLIGHT DECK CREW DUTIES CHECKLIST IN THE DITCHING/CRASH LANDING PROCEDURES SECTION (1) TO MAKE THEM CONSISTENT WITH THOSE PROCEDURES IN THE FLIGHT ATTENDANT MANUAL REGARDING THE COCKPIT CREW INFORMING THE FLIGHT ATTENDANTS OF THE NATURE OF THE EMERGENCY AND THE APPROXIMATE TIME AVAILABLE FOR CABIN PREPARATION, AND (2) TO PRESCRIBE A STANDARDIZED SIGNAL TO FLIGHT ATTENDANTS TO DIRECT PASSENGERS TO ASSUME THE BRACE POSITION. (Closed - Acceptable Action)
Issued: 29-MAR-1984	To: FAA	A-84-18
REQUIRE AIR CARRIER OPERATIONS INSPECTORS TO REVIEW AND TO REQUIRE MODIFICATION AS NEEDED OF THE FLIGHT MANUALS, FLIGHT ATTENDANT MANUALS, AND TRAINING PROGRAMS OF THEIR RESPECTIVE AIR CARRIERS TO ASSURE COMPATIBILITY OF EMERGENCY PROCEDURES AND CHECKLISTS. SPECIFIC ATTENTION SHOULD BE GIVEN TO COMMUNICATIONS AMONG CREWMEMBERS DURING EMERGENCIES, INCLUDING A REQUIREMENT THAT THE COCKPIT CREW INFORM THE FLIGHT ATTENDANTS OF THE NATURE OF THE EMERGENCY AND THE APPROXIMATE TIME AVAILABLE FOR CABIN PREPARATION, AND A STANDARDIZED SIGNAL TO FLIGHT ATTENDANTS TO DIRECT PASSENGERS TO ASSUME THE BRACE POSITION. (Closed - Acceptable Action)
Issued: 29-MAR-1984	To: FAA	A-84-19
INITIATE A RESEARCH AND DEVELOPMENT PROJECT DIRECTED AT REVISING THE MINIMUM PERFORMANCE STANDARDS FOR LIFE PRESERVERS CONTAINED IN TECHNICAL STANDARD ORDER (TSO) C13D, TO REQUIRE THAT THE LIFE PRESERVERS MANUFACTURED UNDER THIS STANDARD CAN BE DONNED IN A MINIMUM TIME BY THE AVERAGE PASSENGER WITHOUT ASSISTANCE WHILE SEATED WITH THE LAP BELT FASTENED. (Closed - Acceptable Action)
Issued: 29-MAR-1984	To: FAA	A-84-20
Revise 14 CFR 121 to require the installation of TSO-C13D life vests on all air carrier aircraft within 12 months of the effective date of TSO-C13D. (Superseded by A-85-35 through A-85-49) (Closed - Superseded)
Issued: 29-MAR-1984	To: FAA	A-84-8
PROVIDE FAA AIR CARRIER INSPECTORS, FOR USE IN THEIR SURVEILLANCE ACTIVITIES, FAILURE TREND INFORMATION BASED ON AIRLINE MAINTENANCE DATA WHICH HAVE BEEN REPORTED BY AIRLINES, AND ANALYZED AND RANKED BY THE FAA FOR THEIR SIGNIFICANCE ON FLIGHT SAFETY. (Closed - Acceptable Action)
Issued: 29-MAR-1984	To: FAA	A-84-9
REQUIRE THE FEDERAL AVIATION ADMINISTRATION\'S PRINCIPAL MAINTENANCE INSPECTORS TO DOCUMENT AND REPORT PERIODICALLY ON THE EFFECTIVENESS OF FAA-DIRECTED ACTIONS TO CORRECT DEFICIENCIES DETECTED DURING SURVEILLANCE ACTIVITIES. (Closed - Acceptable Action)
Issued: 07-MAY-1984	To: Eastern Air Lines	A-84-42
REVISE ITS FLIGHT MANUAL EMERGENCY LANDING/DITCHING CHECKLIST IN THE EMERGENCY PROCEDURES SECTION, THE FLIGHT DECK CREW DUTIES CHECKLIST IN THE DITCHING/CRASH LANDING PROCEDURES SECTION, AND THE FLIGHT ATTENDANT MANUAL (1) TO MAKE THEM CONSISTENT REGARDING THE FLIGHTCREW INFORMING THE FLIGHT ATTENDANTS OF THE NATURE OF THE EMERGENCY AND THE APPROXIMATE TIME AVAILABLE FOR CABIN PREPARATION; AND (2) TO PRESCRIBE A STANDARDIZED SIGNAL FROM THE FLIGHTCREW TO FLIGHT ATTENDANTS TO DIRECT PASSENGERS TO ASSUME THE BRACE POSITION. (Closed - Acceptable Action)
Issued: 07-MAY-1984	To: Eastern Air Lines	A-84-43
REVIEW AND MODIFY AS NEEDED, ITS FLIGHT MANUALS, FLIGHT ATTENDANT MANUALS, AND TRAINING PROGRAMS TO ASSURE COMPATIBILITY OF EMERGENCY PROCEDURES AND CHECKLISTS, AND TO REQUIRE JOINT COCKPIT AND CABIN CREW TRAINING WITH RESPECT TO EMERGENCY PROCEDURES; SPECIFIC ATTENTION SHOULD BE GIVEN TO CONDUCTING PERIODIC EMERGENCY DRILLS IN WHICH COCKPIT/CABIN CREW COORDINATION AND COMMUNICATION ARE PRACTICED AND PASSENGER BRIEFINGS ARE SIMULATED REGARDING EVENTS THAT MAY BE EXPECTED DURING SUCH EMERGENCIES. (Closed - Acceptable Action)
Issued: 07-MAY-1984	To: Eastern Air Lines	A-84-44
REVISE, AS REQUIRED, ITS PREDEPARTURE ORAL BRIEFING AND SUPPLEMENTARY SAFETY BRIEFING CARDS TO ENSURE THAT EACH ACCURATELY DEMONSTRATES OR DESCRIBES ALL STEPS NECESSARY FOR PASSENGERS TO LOCATE AND RECOVER LIFE VESTS FROM THE STOWED POSITION, REMOVE THEM FROM THEIR PLASTIC CONTAINERS, AND DON THEM. (Closed - Unacceptable Action)

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Map

This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Miami International Airport, FL to Nassau International Airport as the crow flies is 294 km (184 miles).

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

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