No fatalities

2017-08-07: Pilatus Aircraft Ltd PC-12/47E (VH-OWS) — Royal Flying Doctors Service of Australia (Western Operations) — Meekatharra Airport, Western Australia

Meekatharra Airport, Western Australia

On August 7, 2017, a Pilatus Aircraft Ltd PC-12/47E (registration VH-OWS) operated by Royal Flying Doctors Service of Australia (Western Operations) was involved in an aviation accident near Meekatharra Airport, Western Australia. No fatalities were reported. Investigators recorded the probable cause as: Parts of the propeller shaft seal were not assembled in the correct order, leading to oil leakage. This summary draws on records from the Australian Transport Safety Bureau (ATSB).

Sourcesthe Australian Transport Safety Bureau (ATSB)Primary reportUpdated 1779789295Data APIEditorial standards
Aircraft registered VH-OWS
Aircraft registered VH-OWS. Photo: Calistemon / CC BY-SA 4.0, via Wikimedia Commons

An investigation found oil leaking from a propeller shaft seal because it was assembled incorrectly. The half flat spacer was placed forward instead of aft, causing abnormal wear. The engineer used an incorrect diagram and relied on memory, potentially influenced by fatigue.

Incident Description

Oil was observed leaking from the propeller shaft seal assembly. An investigation revealed that the seal components had not been assembled in the correct sequence. Specifically, the half flat spacer was positioned forward of the seal rather than aft. This misplacement compressed the seal and forced it against the seal runner. The resulting friction from the rotating seal runner caused abnormal wear, enabling engine oil to escape.

Assembly Process

During assembly, the engineer consulted the Illustrated Parts Catalog (IPC) diagram rather than the Engine Maintenance Manual (EMM) diagram, which depicted the correct order of parts. Although the engineer referred to the EMM, he did not notice that its assembly procedure and diagram differed from those in the IPC. Additionally, the engineer relied on his memory of the order in which the parts were removed. The investigation noted that this recall may have been affected by fatigue associated with longer working hours and disrupted sleep.

Findings

The oil leak originated from the incorrect assembly order of the propeller shaft seal components. The error occurred because the engineer followed the IPC diagram instead of the EMM diagram and depended on memory, which may have been impaired by fatigue from extended work hours and irregular sleep.

Probable cause

Parts of the propeller shaft seal were not assembled in the correct order, leading to oil leakage.