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ASN Wikibase Occurrence # 227991
Last updated: 1 August 2020
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Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different
Boeing 737-8LD (WL)
Registration: ZS-ZWE
C/n / msn: 40854/5518
Fatalities:Fatalities: 0 / Occupants: 200
Other fatalities:0
Aircraft damage: None
Location:30 nm from Lanseria -   South Africa
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Cape Town International Airport (CPT/FACT)
Destination airport:Lanseria International Airport (HLA/FALA)
Investigating agency: CAA SouthAfrica
Kulula flight number MN494 was in a flight to Lanseria Aerodrome (FALA) from Cape Town international Aerodrome (FACT). On board the aircraft was a crew of 6 and 194 passengers on board. Some 10 nautical miles (Nm) prior to initiating a descent, the crew noticed a number 1 engine low oil quantity indication warning caption reading 17%. Following the warning, the crew followed requirements of the emergency check list and contacted FALA air traffic control (ATC) requested an early descend from FL330 to FL210, and they stated the emergency situation. The crew contacted the maintenance control centre (MCC) to request further technical assistance. The MCC advised the crew to continue to FALA and monitor the aircraft engine oil quantity until it run to 0% on which they can commence with an engine shutdown.
The MCC also requested that the crew divert to OR Tambo International Aerodrome (FAOR) in case the number 1 engine oil quantity dropped to 0% prior to reaching FALA and if it was permissible for the flight. The crew proceeded to FALA and kept consistent monitoring of the aircraft engine oil quantity indication that did not stop reducing. Upon reaching FALA when the aircraft was overhead the engine low oil quantity indication reached 0% and the crew requested a go around and diverted to FAOR and permission was granted. An inflight engine shutdown procedure was carried out by the crew and the number 1 engine was shutdown. The aircraft proceeded to FAOR and requested a further descend to FL110 and was handed to RADAR monitoring procedure. On approach for FAOR emergency landing procedure were carried out by the crew and the airport emergency fire and rescue (AEFRS) were put on standby. The aircraft landed safely on runway 21L and was escorted to the apron by the AEFRS.
The aircraft resumed service on 14 July 2019.

Probable Cause/s
The starter oil drain/fill magnetic plug separated during a flight from FACT to FALA as it was not locked after maintenance which was undertaken the previous day. This resulted in the oil leaking from the engine number 1 through the starter oil drain/fill port.
Contributory Factors:
1 The AME, when performing a starter change, relied on the information he was given by the base station in FACT, and not the AMM.
2 The AME was overwhelmed with work on 7 July 2019 due to extra maintenance required on the defected engine number 1 starter.


Accident investigation:
Investigating agency: CAA SouthAfrica
Status: Investigation completed
Duration: 1 year
Download report: Final report

Revision history:

07-Aug-2019 14:36 harro Added
07-Aug-2019 14:39 harro Updated [Narrative]

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