May 5, 1983
NTSB Number: AAR-84-04
NTIS Number: PB84-910404
At 0856, on May 5, 1983, Eastern Air Lines, Inc., Flight 855, a Lockheed L-1011, N334EA, with 10 crewmembers and 162 passengers on board, departed Miami International Airport en route to Nassau, Bahamas. About 0915:16, while descending through 15,000 feet, the low oil pressure light on the 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 0928:20, while at 16,000 feet, the No. 3 engine flamed out. At 0933:20, the No. 1 engine flamed out while the flight crew 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 0946. There were no injuries to occupants.
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