| Status: | Definitief |
| Datum: | 05 MEI 1983 |
| Tijd: | 09:46 |
| Type: | Lockheed L-1011 TriStar 1 |
| Luchtvaartmaatschappij: | Eastern Air Lines |
| Registratie: | N334EA |
| Constructienummer: | 1141 |
| Bouwjaar: | 1976 |
| Motoren: | 3 Rolls Royce RB211-22B |
| Bemanning: | slachtoffers: 0 / inzittenden: 10 |
| Passagiers: | slachtoffers: 0 / inzittenden: 162 |
| Totaal: | slachtoffers: 0 / inzittenden: 172 |
| Schade: | Geen |
| Plaats: | Miami International Airport, FL (MIA) (Verenigde Staten)
|
| Fase: | Kruisvlucht (ENR) |
| Soort vlucht: | Internationale lijnvlucht |
| Vliegveld van vertrek: | Miami International Airport, FL (MIA/KMIA), Verenigde Staten |
| Vliegveld van aankomst: | Nassau International Airport (NAS/MYNN), Bahamas |
Beschrijving: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 FL 200. 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: "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."
Bronnen:
» NTSB
Veiligheidsmaatregelen
NTSB issued 9 Safety Recommendations
| Issued: 29-MAR-1984 | To: FAA | A-84-008 |
| 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-84-009 |
| 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: 29-MAR-1984 | To: FAA | A-84-017 |
| 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-84-018 |
| 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-84-019 |
| 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-84-020 |
| 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: 07-MAY-1984 | To: Eastern Air Lines | A-84-042 |
| 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-84-043 |
| 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-84-044 |
| 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) |
Show all AD's and Safety Recommendations
Foto's
Kaart
Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft
niet de exacte vliegroute weer.
De afstand tussen Miami International Airport, FL en Nassau International Airport bedraagt 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.
