The Safety Board's full report on this investigation is provided as Aviation Accident Report number AAR-84/04. To obtain a copy of this report, or to view the executive summary online, please see the Web site at http://www.ntsb.gov/publictn/publictn.htm


DESCENDING THRU 15000 FT INTO NASSAU THE #2 ENG WAS SHUT DOWN DUE TO LOW OIL PRESS. AT 16000 FT RETURNING TO MIAMI THE #3 ENG FLAMED OUT, & 3 MIN LATER THE #1 ENG FLAMED OUT. THE ACFT BEGAN DESCENDING WITHOUT POWER FROM 13000 FT. AT ABOUT 10000 FT THE FLIGHTCREW ANNOUNCED THAT DITCHING WAS IMMINENT. THE #2 ENG WAS RESTARTED AT 4000 FT, & THE ACFT MADE A ONE-ENG LANDING AT MIAMI. ALL O-RING SEALS IN THE MASTER CHIP DETECTOR ASSY'S IN THE ENG LUBRICATION SYSTEM WERE MISSING CAUSING OIL LEAKS IN ALL ENGS. PROPER PROCEDURES TO REMOVE, REINSTALL & INSPECT THE DETECTORS FOR OIL LEAKS WEREAVAILABLE. THE FOREMAN KNEW THAT MECHANICS WERE NOT ROUTINELY REPLACING O-RING SEALS. ACCIDENT WAS 9TH CHIP DETECTOR OCCURRENCE SINCE PROCEDURES WERE REVISED 12/81. FAA AWARE OF PROBLEMS ON EAL ACFT BUT DID NOT ASSIGN SPECIAL SURVEILLANCE PRIORITY TO THEM. ATTENDANTS NOT AWARE OF TIME AVAILABLE TO PREPARE CABIN FOR DITCHING. PAX HAD DIFFICULTY LOCATING & DONNING LIFE VESTS.

The National Transportation Safety Board determines the probable cause(s) of this incident as follows:

Contributing Factors

INADEQUATE SURVEILLANCE OF OPERATION..FAA(ORGANIZATION)
AIRCRAFT PERFORMANCE,TWO OR MORE ENGINES..FAILURE,TOTAL

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