AAIB Report into 3-Engined 747 over London

[Jordan D]

Before this story gets out of hand (it already has on the BBC), here's the BBC Report (without reference to when the incident occured)

http://news.bbc.co.uk/1/hi/uk/4604466.stm

Here's the source, citting occurance in April 2004.

http://www.aaib.dft.gov.uk/publications/bulletins/january_2006.cfm
http://www.aaib.dft.gov.uk/publications/bulletins/january_2006/boeing_747_132__n481ev.cfm

The last link includes link to pdf for full report.

Jordan

[Skywards747]

. Jumbos can fly on 3 engines without a problem.


Of course, they can. BA proved that beyond any doubt.

[Parapunter]

The problem on this occassion according to the report was that the remaining three engines failed to increase thrust when the throttles were advanced and decaying airspeed was noted. The captain elected to land rather than risk flame out on any of the three remaining engines.

[GT3]

And was the fuel not contaminated?

[ORAC]

No problem later found with the other 3 engines or the fuel. No subsequent problems with the jet. Doesn´t really pin down the cause, but the point is the crew didn´t think they had the power to maintain level flight and thought they needed to glide to a suitable runway, ATC weren´t told of the full severity of the problem and let them route over central London.

So the potential situation existed of a underpowered 474 failing to reach the runway and going down somewhere in the city.

[Avman]

I must say that I do find it total madness to allow a heavy cargo aeroplane -with reported thrust problems on its remaining engines - to make an approach over a major city. There were surely plenty of alternatives around (e.g. Manston, Ostend and even Stansted) within "gliding" distance.

[Wycombe]

...and a similar thing had happened previously with a Gemini DC10, which following an uncontained engine failure was routed over central London into LHR...if I remember correct he had been offered Brize (emergency started over Western UK) but went to Heathrow at Commanders request.

Stand to be corrected, it was a while ago.

[AlanM]

Interesting one this.

Suurely the aircraft commander should make the decision (maybe with a little bit of info from ATC regarding the built up areas on route)

Would take a brave ATCO to say NO to an emergency request, especially if it went a few miles extra to another airport and it then crashed short final.

Safety Recommendation 2005-069
The Civil Aviation Authority (CAA) should review the guidance provided in the Manual of Air Traffic Services (MATS) Part 1 and Civil Aviation Publication (CAP) 475 (The Directory Of CAA Approved Organisations) and consider whether ATC unit Training for Unusual Circumstances and Emergencies (TRUCE) plans adequately prepare controllers to handle aircraft in emergency, and in particular, whether sufficient guidance is provided on the avoidance of built-up areas when vectoring aircraft in emergency. Where considered necessary, this guidance should be amended as soon as practicable.

.........interesting to see that TC staff who have not done any TRM yet will be doing TRM instead of TRUCE this year.

[ALLDAYDELI]

Wycombe, I remember the said DC10 incident one Sunday night, that was out of SNN and came all the way to LHR. Replacement aircraft they flew in then went tech as well ...

[Del Prado]

Glad this story has made it to PPRUNE.

If the commander calls a Mayday or Pan and requests a diversion to Heathrow, then I, as an Atco, am not going to debate the point until there are clear guidlines laid down about vectoring aircraft in difficulty over central London.

Interesting to hear the pilot was praised in the report, IMHO ATC also did a stunning job in getting what was an aircraft that couldn't maintain height, safely down through a very busy TMA.

[Two's in]

With due deference to Jackonicko, don't forget that hyperbole and exaggeration are the norm for these stories, and luckily, the Times online didn't let me down...
http://www.timesonline.co.uk/article/0,,2-1981933,00.html
Jumbo with engine failure flew over London
By Simon Freeman
The crew of a Boeing 747 with engine failure that was losing power and altitude took a potentially catastrophic diversion over Central London, it was revealed today.
The jumbo jet was on a cargo flight from Ramstein in Germany to New York when its four-man crew realised that one of the four engines had cut out.
The captain made a U-turn over Reading and - without the appropriate maps - decided to head back to Heathrow, which he had spotted out of the window earlier.
Their figure-of-eight course took the aircraft within ten miles of Gatwick as it looped across Sussex and Kent before mayday was declared.
The aircraft performed a series of sharp turns over Central London as it fought to gain height before reaching Heathrow.
There, the pilot had only his experience to rely on as he guided the Evergreen International Airlines jet onto the runway. There were no instructions in the operations manual as to how the plane would perform in 'glide mode'.

[Wycombe]

....I thought that the need to loose height was the reason for the 270 and then the S turns. Great example of how one incorrect word can completely change (and render incorrect) that part of the story :mad:

[clicker]

As we have said in the past Jouno's read what they want and not the full facts.

"The aircraft performed a series of sharp turns over Central London as it fought to gain height before reaching Heathrow."

Well not according to AAIB, as I understand it it was to lose the height, ready for the approach into Heathrow.

As far as I'm concerned I would rather a crew, in similar circs, went for an airfield they knew they could make, rather than be diverted to a field by ATC which they would perhaps not make it. As already mentioned it would be a brave ATCO not to go with the crew's request's.

The jouno's are reading to much into the report's "what if" comments.

[epreye]

The critical factor in choosing LHR was VMC.

The report is quite emphatic that they probably would not have made it in IMC conditions.

A successful outcome to something as critical as this, speaks volumes for the skill of the crew and ATC. I'd fly with that crew anytime!

[Lookatthesky]

Quote:


"The report said the pilot's manoeuvres would not have been possible if the weather had been worse"

You can only react to the prevelant weather conditions!! What a non-sensical statement!!

I guess that if the vis was 50m in freezing fog, then he would not have been able to make the approach :\

[Del Prado]

"I have seen the radar tape & listened to the RT; in my opinion, the combination of ATC & piloting was exemplary when considering the worst case option of a 4 engined flame out"

Hear Hear Mike

[markflyer6580]

'glide mode'.

Is there a button for that,or is it an automatic thing:}

[cwatters]

Quote:
"The report said the pilot's manoeuvres would not have been possible if the weather had been worse"
You can only react to the prevelant weather conditions!! What a non-sensical statement!!

No it makes perfect sense. It's having a dig at the Ops Manual. What it's trying to say is that if the weather had been bad the pilot would have had to make a more conventional straight approach and that this would not have been possible due to a lack of... "guidance available within the Operations Manual on the glide performance of the aircraft or glide approach technique".

In other words those S turns probably wern't just to get down to the normal glide slope - he was mentally working out the engine off glide slope and getting set up for that. I'm even more impressed.

Later Edit: Very worrying that no fault found!

[RRAAMJET]

What a pathetic piece of drivel by 'The Times'....don't tell me - their crossword now has clues with pictures (I used to like to do it) :uhoh:

[nicholasw]

What a pathetic piece of drivel by 'The Times'....don't tell me - their crossword now has clues with pictures (I used to like to do it) :uhoh:
I like the bit in the BBC version of the story where the author confuses the reference to 'FL210' for the aircraft flight number :=

http://news.bbc.co.uk/1/hi/uk/4605250.stm

[Leezyjet]

I just missed the landing by a matter of seconds, saw it turn off the runway and taxi in though whilst wondering what it was doing in LHR. From the guys I spoke to who did see it, they said it was one of those that makes you stop what your doing and look.

[Kalium Chloride]

Can I ask a simple question?

Where on earth is "Wright Field, New York State"?

Tried to find it on the Internet and the place doesn't seem to exist.

[the_hawk]

Good question, wikipedia sends http://en.wikipedia.org/wiki/Wright_Field to Wright Patterson AFB, but that's in Ohio

[ALLDAYDELI]

WRI Wrightstown McGuire New Jersey USA

[Taildragger67]

Nicholasw,

Looks like the Beeb got shelled over the FL/flight number stuff-up and have removed it.

[Jordan D]

Note also that the BBC article now has a date of the incident on it.

Maybe they read here?

Jordan

[Kalium Chloride]

WRI Wrightstown McGuire New Jersey USA


There's also a Caldwell-Wright Airport in New Jersey - but neither of these is New York State, as clearly mentioned by AAIB. I also heard the original Evergreen statement said the 747 was going to JFK. Anyone clear this up?

[Gainesy]

as it looped across Sussex and Kent before mayday was declared.


Bit of a show off?:rolleyes:

[GotTheTshirt]

I notice the comments about "how would it look if the aircraft was diverted by ATC and then fell short of the alternate airfield "

Well gliding through a block of flats and public buildings in London would not exactly be good press !:uhoh:

[the_hawk]

Exactly, even more when
The airline was conducting flights in support of the US military and it was not known if there were Dangerous Goods onboard.
...and because of the military nature it may never be known...El Al and Schiphol 1992 was not so good press

[Del Prado]

I notice the comments about "how would it look if the aircraft was diverted by ATC and then fell short of the alternate airfield "

Well gliding through a block of flats and public buildings in London would not exactly be good press !

That's the point. At the time of the emergency you have to make a judgement call (under time pressure) as to whether the flight should continue over a built up area or be diverted to another airfield.
There is practically no guidance available to ATCOs with which to make that judgement call yet should it end badly there will be many experts who, with the benefit of hindsight and time, can make a very convincing case that our decision was the wrong one.

Under these circumstances it would take a very brave ATCO indeed to question a commanders plan of action when controlling an emergency aircraft.

[Navy_Adversary]

I note it's flightpath made it close to Tunbridge Wells:eek:

[Jordan D]

Well indeed - that's the question: if there were dangerous goods, then what would have happened? If there were more power problems then what would have happened? We could keep going on this track ... however decisions were made, which in the end created a happy ending.

The issue of the pilots not having any airfield maps etc with them is possibly more pertient IMHO (as a SLF).

Jordan

[Leezyjet]

Well gliding through a block of flats and public buildings in London would not exactly be good press

For some of the area's close to LHR it would probably have made an improvement ;)

:)

[TSR2]

Headline in todays Daily Express

Jumbo Glides Over Central London After Engines Fail

[411A]

You gotta hand it to the British 'press'...they take a good story, and 'make' it even better.:ok: :ok:

[stormin norman]

Sounds like an ice problem.The question i would ask was why the aircraft not impounded by the CAA ?.

[lomapaseo]

Sounds like an ice problem.The question i would ask was why the aircraft not impounded by the CAA ?.

:confused: :confused:

Care to elaborate on why you feel it was ice?

I'm not aware of any other similar incidents associated with ice.

[GuruCube]

The question i would ask was why the aircraft not impounded by the CAA ?.
Maybe because they already have the Phuket at LGW... think we're going to run out of parking spaces for broken 74's.... :rolleyes:

[Kalium Chloride]

Sounds like an ice problem.


Except that the AAIB doesn't think so:

"One possibility is, of course, atmospheric conditions such as icing but a weather aftercast suggested that the aircraft was flying in conditions that were not conducive to this phenomenon."

[skiesfull]

Having watched the Evergreen B747-200F make its steep turns to lose altitude and make a safe approach and landing, I thought it was a very well flown maneouvre and ATC deserved praise for complying with the Captains' intention to fly a visual approach to an airport with two long runways.
The point about having charts is irrelevant for an emergency landing in clear conditions. ATC will provide relevant information required by the crew.
Regarding icing, fuel icing may have been a factor for the investigation, but airframe icing almost certainly was not, given the weather conditions between Ramstein and Heathrow.
As for impounding the aircraft - for what reasons?
The incident ended safely for all concerned, including all those millions who happened to be under the aircrafts' flight path - why speculate on what horrors may have occurred? Both crew and air traffic controllers acted as trained and in accordance with current legislation.

[punkalouver]

Keeping in mind, I know very little about 747's, it sounds from the report that the crew may have misinterpreted the engine guages or been given faulty information by the engine indication display system. After the engine failure, they descended to FL210 at which point "the air speed began to decrease significantly which the co-pilot drew to the attention of the commander."
There was according to figure three, a 20 knot decrease over two and a half minutes at which point there was a further descent. In the simulator when flying a similar profile with slightly different engines, there was a 20 knot decrease over three minutes.
Further, "The commander was seen by the co-pilot to advance the Nos 2 and 4 thrust levers one at a time but the EPRs remained the same with the EGTs increasing to approximately 890ºC with no detectable corresponding forward acceleration. Further operation of the thrust levers was considered but the commander did not wish to compound his problems by possibly flaming out the remaining engines."
The report goes on to quote this from the operator's 747 operations manual "Slow engine acceleration and/or slow EPR response at high altitude could be misinterpreted as lack of engine response to thrust lever movement. Due to the engine inlet air spillage at low thrust settings near idle and the possibility of false EPR indications, other engine parameters should be monitored. If engine thrust appears to be unresponsive in terms of EPR, advance the thrust lever and monitor N1, EGT and Fuel Flow increase; normally EPR should respond in approximately 15 to 20 seconds. Engine acceleration time up to one minute may be experienced. If N1, EGT and Fuel Flow do not respond normally, or if the engine has flamed out, refer to Abnormal Procedures”.
I don't know if FL 210 is considered the high altitude mentioned in this caution.
Power was available on approach and taxi in.
Also important to remember is that when checked on the ground by an engineer, a wet cycle on #1 produced no N1 or FF. #2 engine showed no N1 or FF when started. "the engineer found a BITE (Built-In Test Equipment) fault on the EIDS which led him to change the right-hand display unit and clean the ‘Cannon’ plugs for the EIDS system." The report doesn't mention if there was an attempt to start #3 and #4 before the EIDS was replaced. This could be the source of some or all of the problem after #1 was shut down.