SAIB NE-00-12

SPECIAL

AIRWORTHINESS

INFORMATION

BULLETIN

REGULATORY SUPPORT DIVISION P.O. BOX 26460 OKLAHOMA CITY, OKLAHOMA 73125-0460

U.S. Department of Transportation Federal Aviation Administration

No. NE-00-12 February 1, 2000

SAIB’s are posted on the internet at http://av-info.faa.gov This is issued for informational purposes only and any recommendation for corrective action is not mandatory.

Introduction The purpose of this Special Airworthiness Information Bu lletin (SAIB) is to provide safety information to certificate holders of 14 CFR Part 121 and Part 135.

Background On December 4, 1999, the latest in a number of serious events due to maintenance error on multiple engines occurred during the revenue flight of a transport aircraft . In this most recent event, a maintenance crew had serviced both engines on a twinjet airplane, but had ne glected to properly reconnect all hoses and fittings.

During the subsequent flight, both engines experien ced a complete loss of oil; however, the engines continued running long enough for the airplane to make a safe, on-airport landing.

Over the past 15 years, at least six other serious in cidents, including forced landings, have occurred due to maintenance error on multiple engines on the incident ai rcraft. These events have typically been associated with failure to restore oil, chip detector, or borescope access system integrity.

Safety Information While proper design of maintenance procedures is in tended to reduce the likelihood of error, mistakes do occur. Processes, equipment and environmental conditions may cause or contribute to mistakes. Others are the result of slips, misunderstandings, or fatigue. It h as been estimated that nearly a third of all transport airplane in-flight shutdowns are due to improper or incorrect maintenance (The Boeing Company, "Maintenance Error Decision Aid", 1994). When only a si ngle engine has been serviced prior to any given flight, the result of a maintenance error will likely be no worse than a single-engine in-flight shutdown, which transport airplanes are designed to accommodate. However, when the erro r has been repeated on multiple engines, the result can be a greater loss of to tal engine thrust or power than the airplane can accommodate. In the worst events in the historical database, a complete loss of thrust or power has occurred.

Recommendations The intent of this SAIB is to help minimize the o ccurrence of multiple-engine in-flight shutdown, powerloss, or other anomaly due to maintenance error. Therefore, the FAA recommends that operators avoid performing maintenance on multiple engines installe d on the same aircraft at the same time if at all possible. However, the FAA recognizes that some situations may be unavoidable. If it is not possible to avoid maintenance on more than one engine at the same time, the FAA recommends that different maintenance teams service each engine. Maintenan ce guidelines should be revised, where possible, to promote this recommendation.

For Further Information Contact FAA, Ann Azevedo, ANE-110, 12 New England Executive Park, Burlington, MA 01803;

Tel: (781) 238-7117; Fax: (781) 238-7199; email: ann.azevedo@faa.gov.

CHANGE OF ADDRESS NOTICE

Airworthiness Directives (AD) for a particular make and m odel of aircraft are mailed to the aircraft owners using the permanent mailing address on file with the FAA Registry. If you need to change your address, please complete this form and mail to FAA Aircraft Registration. A revised Certif icate of Aircraft Registration will be mailed to you without charge.

Signature requirements:

— Individual owner must sign.

— Partnership, a general partner must sign.

— Co-owner, each co-owner must si gn, continuing as necessary on an attached sheet.

— Government, any authorized person may sign.

MAIL TO:

FAA Aircraft Registry, AFS-750 Mike Monroney Aeronautical Center P.O. Box 25504 Oklahoma City, OK 73125-0504 AIRCRAFT REGISTRATION NO.

SERIAL NO.

MAKE

MODEL

ADDRESS CHANGE REQUESTED

NAME AND ADDRESS OF CERTIFICATE HOLDER

___________________________________________________________ STREET

___________________________________________________________ CITY

___________________________________________________________

STATE ZIP COUNTRY

SIGNATURE (In Ink)

TITLE

DATE

CANCELLATION OF REGISTRATION REQUESTED:

(check applicable block, sign, and date)

… 1. Aircraft sold to: (Purchaser's name and address)

_________________________________________________________

_________________________________________________________

_________________________________________________________

… 2. Aircraft destroyed/scrapped

… 3. Aircraft exported to _______________________________________________

… 4. Other, specify ___________________________________________________

I (we) request cancellation of registration for the above reason.

SIGNATURE (In Ink)

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U.S. Department of Transportation

Federal Aviation Administration

FIRST-CLASS MAIL

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Regulatory Support Division P.O. Box 26460 Oklahoma City, OK 73125-0460 AFS-610

Official Business Penalty for Private Use $300