British Midland Kegworth Crash on T.V Tonight [Archive]

newswatcher

28th Mar 2001, 15:31

This is part 2 of a 6-part series concentrating on "National Disasters". Looking at the preview, it looks as though it is going to concentrate on the "effect" rather than the "cause".

This is cut from the program listing:

"......including interviews with survivors and rescue workers, many of them speaking publicly for the first time. This edition tells the story of the Kegworth air crash in January 1989 when an error by the pilot resulted in a British Midland Boeing 737 crashing onto the M1 motorway with the loss of 52 lives."

foghorn

28th Mar 2001, 17:28

"error by the pilot".

So that's why it crashed then - it wasn't carrying its normal compliment of two flight crew? Journos :mad:

I'd rather

28th Mar 2001, 17:32

The same programme last week on the Herald of Free Enterprise was CRAP - at least as far as the technical stuff was concerned - inaccurate, used the wrong terminology and betrayed a basic lack of understanding of shipping/navigation etc....

...so I really wouldn't expect too much from tonight's programme, as the media seem to be even shakier on aviation than on nautical matters.

standbyils

28th Mar 2001, 18:07

Here we go again....

Anti Skid On

28th Mar 2001, 18:18

Two point -

firstly, you can access CVR transcripts all over the place (NTSB, AAIB, etc. all have them on the web) - if they were not allowed out on legitimate media, there is a risk they would be 'leaked'

secondly - the Herald - now refloated and repaineted and allegedly working in the southern hemisphere; nice to see the design probs of Ro-Ro's being addressed (NOT) - at least the B737 had a rethink on the engine management systems and confusion re engine numbering (1 & 2, or left and right, or port and starboard!)

Teroc

28th Mar 2001, 19:02

Level of research Airgeezer. Its rare Journos use the info in the official press release as it tends to be factual and true. Cant let that get in the way of
a story can we ?

Sleeve Wing

28th Mar 2001, 20:17

Quite frankly I'm a little hacked off that they've dragged this up again - after all, it happened twelve years ago now.

Maybe I'm a bit naive, but why can't they just let it rest as an unfortunate incident.
Haven't the guys concerned a right to some peace ?

Its pure ill-informed sensationalism and nothing else - how about some decent programmes on the box before we all desert to Sky?
:mad: :mad: :mad:

[This message has been edited by Sleeve Wing (edited 28 March 2001).]

JAGS2

28th Mar 2001, 20:40

NATIONAL DISASTERS 2 21.40 CHANNEL 5

ALBANIA 2 ENGLAND 0

Stall-Warner

28th Mar 2001, 23:02

Chaps,

There is another perspective on this one.

Following the Townsend Thoresen disaster, there was a radical rethink of procedures, not the inherent design faults of Ro-RO ferries. We all know that this ferry design is in use all round the world and legislation cannot just prevent their use because of a (tragic) accident. However, procedures can prevent a repeat. Similar to the Beau Belle tragedy on the Thames - pleasure boats continue to mix with other commercial nautical traffic - procedures have been tightened to make it safe.

I don't think we collectively (ie society) try to hide the major accidents of the past. Sure it was a tragedy for all involved - I had a distant, but personal loss in the BM accident and can only stagger a guess at how it must feel for close F & F.

But, for those who did lose their lives or loved ones, is it not part of the reckoning process to know that SOME good might come from the accident. Let's not forget the lessons immediately learnt in the aftermath of the accident.

We should not be complacent about air travel, nor should we expect others to have such an in depth knowledge of the technical aspects of aviation. We are all experts in our own fields.

I may be wrong and will openly admit it if the research team proves me wrong. But let's not prejudge the outcome until we've seen the portrayal.

God help me if I'm wrong.

SW

airgeezer

29th Mar 2001, 00:44

Stall_warner

I for one agree with your reply. I certainly believe that procedures/cockpit design are at times be less than perfect and often a major factor in mishaps but of course it is so much more convienient to blame the crew outright.

Teroc

press releases are usually only accurate because they contain only part of the story.

Pdub

29th Mar 2001, 02:09

Well, just podting at 1/2 way through the programme, and so far not a bad effort. Normal terminology mistakes "jump start :rolleyes: "

Interesting human factors involved, re:- the reliability of the vibration indicators, and the routing of cabin air.

As a layman found it interesting, would be interested to know how accurate the programme was.

Stall-Warner

29th Mar 2001, 02:36

Well, I don't think any apologies are required from my camp.

airgeezer - you're absolutely right on the blame apportionment side. Thankfully this was mitigated throughout the programme by the fact that inadequate and/or oversights in the training programme partially caused confusion.

Pdub - good to read your comments, even thought you are a lay man...!!! Good observations and I agree with you, technically the facts were reasonably well portrayed. Most of it was straight from the AIB report.

Interesting comment at the end about exterior CCTV - I have my doubts about the effectiveness of such equipment, given the diversity of possible scenarios, but what do others think?

SW

Capt Bankangle

29th Mar 2001, 02:46

Program over,

Not bad compared with the X file garbage a week or so ago BUT did rather gloss over lack of training on specific type.

Bit worried about the fireman -" fuel is basically kerosene mixed with high octane petrol" - did I miss something in BMA's fuel policy?

At least program was not sensationalist!

Georgeablelovehowindia

29th Mar 2001, 03:07

This was a "Human Factors" accident and I think the programme managed to get that message across.
Nitpicking points:
1. Where did the programme makers get the notion that the pressurisation air comes from No.2 engine only?
2. Where did that fireman get the notion that Jet A1 is a kerosene/petrol mix?

It's desperately sad that, but for the lack of a few more precious feet, everyone would have walked away.

[This message has been edited by Georgeablelovehowindia (edited 28 March 2001).]

Teroc

29th Mar 2001, 11:32

Have to say I was pretty pleased with last nights programme. A few errors but nothing like were used to from this kind of broadcast. Overall pretty OK.

Airgeezer,
Agree with you about press releases containing only part of the story. This is more due to pending/upcoming investigations and legal limitations regarding liability etc than an attempt to mislead (generally). But just because part of the story is missing doesnt excuse making the rest of it up. I take it you're involved in the media industry somehow ?

airgeezer

29th Mar 2001, 11:55

Teroc

I was once a cameraman with the BBC, and have worked as a broadcast engineer/lighting director more recently, sadly often on news programmes which means I work with journos.
I find it is more often the egos of producers or poor quality of the researchers that leads to poor, unaccurate reporting but the jounos are often to blame.

GJB

29th Mar 2001, 12:55

My nitpick is that

"The ANGLE of descent was too steep and the plae was travelling too fast"

If it crashed at 132mph, then it sounds like the crew were doing there damnest to keep the nose of the aircraft up and minimise the rate of descent.

I have not read the report but would like to ask your opinions. For such a turbine failure, and the associated engine fire, what sort of readings were the crew getting on their engine instruments?

Was their a failure of some sensors, such that the crew did not realise no1 was on fire?

It was a terrible accident and there were a number of contributory factors. I am only looking for the reasons behind the crew not realising that no1 had failed and was on fire, that lead to them shutting down no2.

LBMF

29th Mar 2001, 13:16

The vib was showing 5 units but this was disregarded by the crew as they had previously being flying DC9s whose vib indication was inaccurate & in some cases deleted.
Crew training hopefully gives better system info, especially for carriers moving from valve aircraft to digital.
The flight manual does not say to shut down for 5 units of vib but to throttle back to 4!

The other problem was that the 737 crews were the "BMA aces". This was the first new aircraft BMA had for years & the cabin crews were scared to go into the flight deck to say about the flames from the left engine.

Yet again not one single event but many - untested engine, crew training & communications front & back.

spannersatcx

29th Mar 2001, 13:33

It was the fan that failed not the turbine. See how easy it is to get things wrong!

seadog

29th Mar 2001, 13:44

Come - on folks, how can you take a program seriously when they interview passengers who were observant to note that " the plane was going really fast when it took off". Wow! A startling revelation in aeronautical theory.
Anyone who's done a CRM course recently will know that a chain of events lead to this accident, and if any one link of the chain was removed the accident would not have happened. The program makers emphasised the First Officer's mis-identification and subsequent shut down of the wrong engine, but how about the reason for the problem in the first place - nothing was said of the overated untested engines which should not have failed. THAT was the initial link in the chain.
Sensational journalism once again proves that any marine or aviation reports wil be a disaster in themselves!

I'd rather

29th Mar 2001, 14:17

To be fair, Seadog, I think all the passenger meant was that it seemed to be a faster take-off than usual (perhaps because he was on a different aircraft than the type he was used to?)

I have to say that I was impressed by the calm, non-hysterical description of events given by the pax - OK, they've had a few years to get over it, but I certainly wouldn't have liked to have been through what they have (this contrasts with my area of work, where after any maritime incident, however small, you can guarantee that someone will get off the boat and say to the nearest camera "It was just like the Titanic")!

PaulDeGearup

29th Mar 2001, 14:47

Regardless of whether the accident is an aircraft, Kegworth, Tenerife, Washington, or a ship, Zeebrugge, Baltic, the incident will throw up some points which we can learn from and thus hopefully avoid finding a repeat of the situation a few years on.

exjet

29th Mar 2001, 15:03

A reasonable programme bearing in mind that it is aired to the general public and not to pilots. With regard to the cameras, most larger corp jets have them, why not the commercials as well?

Anti Skid On

29th Mar 2001, 15:43

Re. CRM - interesting to note that even when the Captain said the Right engine was having problems, no-one questioned it - even the passengers, of those who were interviewed who all said 'Well he must know what he's doing', etc..

The crew are still, above all, TRUSTED. The passengers trusted that they were doing things correctly.

What the programme DID say was that processes could be improved - e.g. line training for type and the analysis of injuries to improve survivability by a new brace position.

swashplate

29th Mar 2001, 17:00

I found it interesting, if a bit simplistic. It wasn't what I'd dreaded! (eg Flights from hell)

But no explanation of why an engine fire in the first place? After all, if it hadn't caught fire, there'd be no mistake in shutdown.
I presume they were actors voices doing the CVR recording - no background noise!!

In about 1992, I remember a much better documentary on this crash on BBC2. It actually featured Capt Kevin Hunt:

"...sure, we made mistakes.....but WHY did we make them?????"

Also, an Irish passenger was saying he wasn't bitter towards the crew. None of these passengers said anything about that.

All in all, not as bad as I'd feared, but not as good as it could have been.

5/10

The Nr Fairy

29th Mar 2001, 17:03

For those interested, the AAIB report can be found at http://www.open.gov.uk/aaib/gobme/gobmerep.htm

It's my understanding that the words "contrary to training" were inserted in the report after the CAA made representations.

OC41

29th Mar 2001, 22:37

Still can remember most vividly the plane going over my house, engine on fire, and noise coming from the broken engine that, at that moment in time, i thought could have only come from a turbo prop. ( BMA had ATP's at the time, was due in around then on the LHR flight and had suffered a few tech probs )

Stall-Warner

29th Mar 2001, 23:06

Pauldegearup,

You echoed the sentiments i made right at the start and 2 hours before the screening.

Let's all not forget the positive aspects that comes out of a tragedy such as this - what's that sad but true catchphrase currently around...

...you can't change the past, but you can influence the future...

Very true within aviation.

SW

euroboy

29th Mar 2001, 23:12

It was the first new a/c that BM operated and dare I say slight "snob" value to working on the 737. There where a few differences us the cabin crew had to get use to between the DC9 and 737, mainly that ALL cabin checks were passed via the interphone including the cabin secure to the Capt. With the DC9 this check was given in the f/d by the No1, so visual and verbal. It makes a BIG difference and gets the crew to mix and gets rid of the them and us. I always found the 9 a "friendly" a/c compared to the 737, before this accident.

Electric Sky

30th Mar 2001, 01:38

Was I being too attentive or was I the only one to hear the diversion destination referred to as "West Midland, Runway 1" right at the start of the programme.The aircraft was actually attempting an approach to East Midlands Runway 27. A minor point maybe but it didn't inspire confidence into the research done behind the programme.

cleared2land 27left

30th Mar 2001, 02:59

ES, yes the WEST mid bit did ring a few bells in my head. The programme did seem short to me, i feel that the CRM part (or TRM as ATCOs know it) could have been highlighted a little more.

"its the left..no right, yes the right engine" that was part of the (acted?) CVR, it did not mention wether the capt or fo said this, but this must have brought some doubt into the other pilot's mind as to which engine it was that had the problem? Well thats the way i think as an ATCO.

Raw Data

30th Mar 2001, 03:24

Speaking of ATCOs, I wasn't very impressed by the EMA ATCO saying that aircraft landing with one shut down was a regular occurance...

eyeinthesky

30th Mar 2001, 14:03

Only got round to watching it on video last night. I, too was surprised at this place West midlands with a runway one, and a foam carpet as well. But I think that was Jon Snow's initial news report on the day rather than the programme's words. Shows, as many threads comment, how little understanding the press have of matters aviation.

As for the comment about the ATCO saying it being a frequent occurrence, perhaps what he meant was that emergencies of some type are common (hydraulics, sick pax, press probs etc). There is indeed no immediate reason to panic. After all, ETOPS relies upon the premise that 2 engined jets are at least as or more reliable than 4 engined ones. If one is shut down then it's no emergency, just a minor inconvenience necessitating a diversion, we are told.

------------------
"Take-off is optional, Landing is mandatory"

scanscanscan

30th Mar 2001, 19:10

I recall and (please correct me if I am wrong)that the captain hurt his back as he "submarined" because his crotch strap was not secure.
The fo was secured.
Also the investigator said that his last three two man crew jet crashe investigations, all had the same script and features, 1. The f/o was handling,the malfunction occured, the captain said I have control,and the auto pilot was then disconected. So he suggested when confused please do the opposite!
If all the throttels are closed, it is more difficult to ident the malfunctioning engine vibs.
If the capt then asks the fo to ident the problem vibs he does not now have much chance of an accurate input.
The high number of atc and radio calls constantly overloaded the crew IMHO and what they really needed then was a good flight engineer.
One guy to fly, one guy to manage the flight,and ident/confirm/ order the correct drill and monitor the f/e doing the drill.
If this crew were confused then they were not "crew awarness" and they need not have taken any action except fly the aircraft to the nearest suitable airport.
A rushed and very brief conversion and differences course was also mentioned at the time as a contributary factor.
We should remember that our crm today is only because of the cost effective accidents and deaths of the past and but for the grace of our Gods etc.

------------------
We will do the drill according to the amendments to the amendments I er think?

tilii

31st Mar 2001, 02:15

Could we get a little wider perspective going on this thread, please?

I for one am sick and tired of hearing people concentrate on the CRM (for want of a better phrase) issue which seems to have overridden all other contributing factors. I knew both these pilots and they were neither incompetent nor prone to error.

As I recall, there were more than 30 recommendations flowing from the investigation into this very sad accident. Only one was related to a CRM issue. Others related to recommendations for action by the manufacturer and the regulatory authority, primarily with regard to design features and proper training for this type of emergency.

Can we please stop making the lives of these two unfortunate chaps a bloody misery in circumstances where it might well have been any one of us?

[This message has been edited by tilii (edited 30 March 2001).]

cleared2land 27left

31st Mar 2001, 03:10

In response to the ATCO saying "we have an emergency every day" or whatever were his actual words, yes that is true and 99% work out OK, but this was after all sensationalist jurno stuff. Joe Public hears this and thinks oh my god and engine out each day, ill never fly again. Yet again more press crap.

Was watching discovery today at work and there was on interesting stat:

Per journey (not per mile) your are 2000 times safer in a roller-coaster than a plane, im sure as hell know which id rather be in! - it has two wings and two guys on it with you who also want to get there safely.

SKYDRIFTER

1st Apr 2001, 04:06

CRM -

CRM is enough of a culprit to keep discussing until the industry gets the science into the norms of crew lives.

While we probably all agree on the potential for highly understandable crew error, there are two prominent lessons available:

1. For the purposes of CRM, the flight attendants are a critical part of the CRM team.

2. Engine shutdowns should not be automatic without a confirmed or highly suspect engine fire or indications of imminent severe damage.

There's an old adage from the piston days, "Unless you have a fire, never shut down an engine packing its own weight."

We can't turn back the clock. This accident can only provide lessons. We fail as pilots if we don't learn and apply those lessons.

In that fashion, the deceased can at least leave that much of a legacy; otherwise, they have died for naught.

Pielander

1st Apr 2001, 04:45

SKYDRIFTER

Excellent point. The AAIB report sait that the fo said that he "could not recall what it was that led him to shut down the right engine", in which case, why was he in such a rush to shut it down? That's not to say that it's OK that the engine threw a fan blade in the first place, but the aircraft is designed to fly on one good engine, so the real issue seems to be CRM. If I remember correctly, this was the 6th such incident involving the CFM56-3C, but it was the only one involving the loss of an a/c. Tragic, and also unnecessary.

tilii

1st Apr 2001, 15:20

Skydrifter

You said: "Engine shutdowns should not be automatic without a confirmed or highly suspect engine fire or indications of imminent severe damage. There's an old adage from the piston days, "Unless you have a fire, never shut down an engine packing its own weight."

I would just like to add that it is now widely accepted that (catastrophic failure excepted) an engine on fire is likely to be producing greater thrust than in normal operation and for that very reason should not be shut down hastily. Especially on takeoff, an engine on fire may just produce enough thrust to carry you safely beyond obstructions and permit you the time to deal with it in a competent manner.

SKYDRIFTER

1st Apr 2001, 17:37

Tilii -

Good point. I forgot to mention that. Standard teaching for critical flight regimes such as takeoff, go-around- and short-final.

Sad part of today's world is that inexpensive miniature video cameras are available to look at such places as engine compartments and cargo holds, yet, I've yet to hear a proposal to add them. At best, you'd have an inexpensive 10 pounds with a terrific safety edge.

Bleed leaks are common fire warning culprits, so the conclusion is obvious.

As to the engine, the series had a brief history of fan failures, such that they were on reduced thrust for a while. I never heard the whole story on that matter.