Peruvian B732 at Tarapoto on Mar 24th 2015, engine oil low pressure, then engine oil filter warning

Last Update: April 26, 2016 / 14:57:15 GMT/Zulu time

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Incident Facts

Date of incident
Mar 24, 2015

Classification
Report

Flight number
P9-128

Departure
Lima, Perú

Destination
Tarapoto, Perú

Aircraft Registration
OB-1851-P

Aircraft Type
Boeing 737-200

ICAO Type Designator
B732

A Peruvian Airlines Boeing 737-200, registration OB-1851-P performing flight P9-128 from Lima to Tarapoto (Peru), was on final approach to Tarapoto about 3nm from touchdown when the right hand engine's (JT8D) low oil pressure light illuminated prompting the crew to idle the engine and continue for a safe touchdown, as the light persisted the engine was shut down during the roll out.

Peru's Comision de Investigacion de Accidentes de Aviacion (CIAA) reported, that maintenance subsequently replaced the gear box.

The CIAA continued that following the replacement of the gear box the aircraft departed Tarapoto for a ferry flight to Lima on Mar 29th 2015 but about 120nm out of Lima the crew received an oil filter bypass warning. The crew idled the engine, the warning extinguished. Following the procedures the thrust levers were advanced again, the warning light illuminated again and did not extinguish again when the thrust levers were pulled to idle again prompting the crew to shut the engine down in flight. The aircraft continued to Lima for a safe landing. The occurrence during this ferry flight was rated a serious incident prompting a CIAA investigation.

The CIAA released their final report in Spanish into the ferry flight concluding the probable causes of the incident were:

Engine #2 Oil System Failure due to contamination as result of improper installation and monitoring of installation of the gear box.

Contributing factors were:

The lack of supervision of works performed by the operator to maintain and inspect OB-1851-P by the Office of Airworthiness Management (OGAC).

The lack of procedures in receiving and installing components such as gear boxes with respect to origin and technical condition.

Failure to follow established procedures in receiving the occurrence gear box.

The CIAA analysed that following the low oil pressure indication on Mar 24th 2015 maintenance personnel positioned from Lima to Tarapoto and in following the troubleshooting instructions of the maintenance manuals detected that the engine's gear box was leaking oil. Maintenance decided to replace the leaking gear box with another gear box that had been repaired. Following the installation an engine test run was performed and was found satisfactorily, the aircraft was released for its ferry flight to Lima.

However, the CIAA analysed, the maintenance procedure had not ensured that the repaired gear box now installed was free of contaminations, which subsequently, during the ferry flight, causing the engine oil filter to clog resulting in the oil filter warning light and subsequent shutdown of the engine.

The non-compliance with existing as well as lack of procedures in receiving a component, in particular to verify the condition of the component to be free of contaminations, permitted the second occurrence gear box to be installed on the occurrence engine despite not being in the required technical condition.

In both cases, the CIAA analysed, the flight crews were following procedures properly, their actions did not contribute to the chain of events leading to the serious incident.

The CIAA analysed that Peruvian Airlines consisted of two branches, one responsible for flight operations having received a valid AOC and one for maintenance properly certified as a maintenance organisation. However, the CIAA stated, there was no evidence that the maintenance organisation and its current works had undergone any supervision by the authorities (OGAC). The CIAA thundered that this lack of oversight was crucial however as the maintenance organisation failed to implement a defense of safety barriers resulting in the non-presence of technical personnel to monitor the maintenance work and to apply corrections as necessary.

The CIAA analysed that following the decision to replace the gear box a suitable replacement was selected from the stock components available. This gear box had been revised in an earlier repair work and had been signed off to be airworthy. However, the supervisor signed the gear box off without specifying that the component still needed cleaning. As result the gear box was put on stock without the necessary cleaning.

In addition there were no records of how long the component had been held in storage or the status of embalmment.

Maintenance staff installing the revised gear box onto OB-1851-P did not perform a visual examination of the component to be installed to verify the technical condition of the gear box, therefore did not detect the contamination by embalmment applied to prevent corrosion during the time in storage and did not perform the necessary steps to clean the gear box, in particular remove the embalmment.

Laboratory examinations of the revised gear box, after the occurrence flight, found contamination consisting of organic matters consisting of the intended lubricating oil mixed with fat, polymers, resin and others. These substances saturated the filtration capabilities of the engine oil filter.

The CIAA concluded analysis stating that none of the existing procedures to receive and install this component to the engine was effective in preventing installing a contaminated component.
Incident Facts

Date of incident
Mar 24, 2015

Classification
Report

Flight number
P9-128

Departure
Lima, Perú

Destination
Tarapoto, Perú

Aircraft Registration
OB-1851-P

Aircraft Type
Boeing 737-200

ICAO Type Designator
B732

This article is published under license from Avherald.com. © of text by Avherald.com.
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