ASN Wikibase Occurrence # 232968
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| Date: | Friday 8 November 2019 |
| Time: | 07:20 UTC |
| Type: |  Cessna S550 Citation S/II |
| Owner/operator: | South African Civil Aviation Authority |
| Registration: | ZS-CAR |
| MSN: | S550-0078 |
| Year of manufacture: | 1986 |
| Fatalities: | Fatalities: 0 / Occupants: 4 |
| Aircraft damage: | Minor |
| Category: | Serious incident |
| Location: | Lanseria International Aerodrome (FALA) -
 South Africa
|
| Phase: | Take off |
| Nature: | Calibration/Inspection |
| Departure airport: | Lanseria International Airport (HLA/FALA) |
| Polokwane International Airport (FAPP) | |
| Investigating agency: | CAA S.A. |
| Confidence Rating: |  Information verified through data from accident investigation authorities |
On Thursday, 7 November 2019 the crew reported smoke in the cockpit during a go-around at Wonderboom Aerodrome (FAWB). After landing the crew conducted an inspection of both engines and there was no oil visible on the dipstick on the No. 1 engine.
The crew made an entry in the flight folio. The AMO attended to the defect and following the maintenance checks, which included a ground run on both engines the defect was signed out in the flight folio and work pack before the aircraft was returned to service.
The following morning (Friday, 8 November 2019), the aircraft with four on board was scheduled to depart Lanseria International Aerodrome (FALA) for a flight to Polokwane International Aerodrome (FAPP). The start-up and flight profile setup were uneventful. During the take-off roll from runway 07 the crew experienced smoke in the cockpit. The crew decided to abort the take off and the aircraft was taxied back to the hangar area before the engines were shut down. After the aircraft was parked, it was discovered that the right main gear tyre deflated and minutes thereafter the left main gear tyre also deflated. The crew did not report any injuries.
The investigation revealed that during the take-off roll, the crew experienced an oil smell and smoke in the cockpit as a result of the number 3 bearing labyrinth seal failure of engine number 1. This caused the oil to leak into the high-pressure compressor (HPC) where the oil mixed with compressed and heated air, resulting in the oil smell and smoke in the cockpit.
Contributory factors:
- The aircraft maintenance organisation (AMO) and the operator were not monitoring the oil consumption of the number 1 engine
- The aircraft maintenance engineer (AME) misdiagnosed the defect as a result of not complying with the manufacturer’s recommended practise
- The operator and the AMO’s non-compliance of safe and standard recommended practises by the manufacturer and the Civil Aviation Regulations
Accident investigation:
 |
|
Sources:
http://www.caa.co.za/Accidents%20and%20Incidents%20Reports/ZS-CAR.pdf
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 15-Feb-2020 14:25 | harro | Added |
| 15-Feb-2020 14:25 | harro | Updated [Source] |
Corrections or additions? ... Edit this accident description
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