This page features a slideshow interaction. Below is a description of each slide with the display text provided alongside them.

Graphic Description

Display Text

A BAe 146.

None

The inside of a cockpit.

Event Description

On January 30, 2018, the BAe 146 departed Midland Airport. Fifteen minutes after takeoff, at 5,000 feet, the oil quantity gauges for Engines 2, 3, and 4 showed empty, and Engine 1 showed near-empty. Shortly after turning back towards Midland, the low oil pressure warning light for Engine 3 illuminated.

The crew shut down the engine and declared an emergency as the low oil pressure lights for Engines 2 and 4 began to illuminate intermittently. With a successful emergency landing, there were no injuries reported for this event.

A mechanic repairing an aircraft engine.

Magnetic Chip Detector Plugs (MCDPs)

After landing, the captain watched as the crew chief checked the engines. The cowls were covered with oil and oil spilled to the ground when the cowls were opened. All four MCDPs were removed and found to have no seals.

A mechanic assembling aircraft parts.

Manpower

The investigation revealed that the maintenance shift in question was supposed to have 12 people – the shift manager, 2 supervisors, 3 senior mechanics, and 6 maintenance technicians. However, one supervisor was home sick and two of the senior mechanics had quit.

Two mechanics working on an aircraft.

Searching for MCDPs

The shift manager directed one of the supervisors to change the MCDPs, though the supervisor had received no engine maintenance training.

MCDP change kits were normally assembled by the night shift, but because of the personnel shortage, the day shift assembled them on request.

A supervisor looking at tools.

Doing It Himself

After finding no MCDP change kits in the maintenance hangar, the supervisor found MCDPs in the area of the engine bay. The MCDPs had been cleaned but not inspected or fitted with seals.

When none of the technicians were available upon his return, the supervisor decided to do the work himself.

Pens on a desk with a folder labeled Procedures.

Aircraft Maintenance Manual (AMM)

The norm at this location was not to use the AMM for simple tasks. So among other steps missed, the supervisor did not check for a new seal for the MCDP or operate the engines to check for oil leaks and satisfactory engine operation.

A mechanic talking with a supervisor.

Sign-Off

The job card required that the work be signed off by the person who performed the work and by the person who supervised the work. The supervisor asked one of the technicians to sign off on the work, so he could then sign off as the supervisor.

The technician agreed, as this was not the first time he had been asked to do something like this. This was the last task for this aircraft, so it was released for service after sign-off.