Engine Failure Due to Contaminated Oil and Maintenance Oversight

Casualties unknown • Fresno, CA, US

An aircraft experienced an uncontained engine failure during cruise flight due to turbine blade detachment caused by contaminated oil that bypassed the filter for over a month.

What happened

The flight proceeded without incident during the initial climb phase, reaching an assigned cruise altitude of Flight Level 260. Approximately forty minutes into the journey, the number three engine suffered a catastrophic mechanical failure. Specifically, the turbine blades on the number four power turbine wheel detached from the disc in an uncontained failure. Despite debris from the engine penetrating the pressure vessel, the pilot successfully executed an unscheduled landing at a nearby airport with no further damage to the airframe or injuries to those onboard.

The investigation

Post-accident examination of the engine revealed critical maintenance deficiencies. Ferroous chips were found contaminating the oil, which had been bypassing the engine oil filter for at least forty days prior to the event. Notably, the oil and filter had been replaced three times in the three months preceding the accident, yet no corrective action was taken by company maintenance personnel to address the underlying issue.

Findings

The investigation determined that the contaminated oil contributed directly to the failure of the number four turbine bearing. This bearing failure led to overheating and subsequent damage to the overspeed sensors. The resulting turbine overspeed caused the blades to depart the disc, initiating the chain of events that led to the engine failure.

Probable cause

The failure of the number four turbine bearing due to contaminated oil bypassing the filter for an extended period, compounded by the lack of corrective action by maintenance personnel despite repeated oil changes.

Frequently asked questions

What happened in the 1987-02-28 British Aerospace BA146-200A accident near Fresno, CA?

An aircraft experienced an uncontained engine failure during cruise flight due to turbine blade detachment caused by contaminated oil that bypassed the filter for over a month.

What aircraft was involved and where did it happen?

The accident on 1987-02-28 involved a British Aerospace BA146-200A, registration N356PS, operated by Pacific Southwest Airlines, at Fresno, CA.

What was the probable cause of the accident?

The failure of the number four turbine bearing due to contaminated oil bypassing the filter for an extended period, compounded by the lack of corrective action by maintenance personnel despite repeated oil changes.

Investigation report by the U.S. National Transportation Safety Board (NTSB) historical archive. Original record: https://carol.ntsb.gov/event/20001213X30257. This page is a structured re-presentation; facts and quotes are in the National Transportation Safety Board (NTSB), United States.

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