Kegworth

[twistedenginestarter]

There was an interesting new Seconds from Disaster the other night. It appeared the co-pilot tried to re-start the good (right) engine but there was insufficient forward speed to get it going. I note however that the APU was started when the engine was first shut down. It looks to me as though on the 737-400 you can only use the APU to start the left engine. Is this the case, and if so what's the logic in that?

[spekesoftly]

From the AAIB report (pages 104/105); at the time of the accident the Quick Reference Handbook gave a procedure suitable only for the restart of the No 1 engine (using APU bleed air) and such an attempt to start No 2 would have required improvisation. The report goes on to say that this check list was subsequently amended to cover the restart of either engine.

[twistedenginestarter]

That suggests the APU is only connected to one engine. Why would that be? What was the solution now in place?

[Sky Wave]

The APU is connected to the left side of the aircraft (the same side as engine No 1). To use APU bleed to start engine No 2 you need to open the isolation valve which then allows bleed air from the left side to feed the right side.

[moggiee]

Of course, correctly identifying the failed engine in the first place would have avoided the problem. Given that the FDR showed "marked fluctuations in N1 speed, high EGT and low, fluctuating fuel flow" on the left engine that should not have been difficult.

[matt_hooks]

With all due respect moggiee, we can ALL have 20/20 (sorry, 6/6) hindsight, but you weren't there on the flightdeck dealing with the emergency.

I'm sure anyone who knows anything about flying knows about Kegworth, and yes, there WERE clues, but the crew were dealing with the situation in a pressured environment and missed them.

They're human, humans make mistakes sometimes!

The design of the cockpit instrumentation iirc was found to have contributed to the accident also.

It was one of those tragic cases where all the holes lined up. For sure we should look at it, and try to learn lessons from it, but to sit there and judge the actions of the flight crew is non-productive and downright disrespectful!

</rant>

[H Peacock]

It was one of those tragic cases where all the holes lined up. For sure we should look at it, and try to learn lessons from it, but to sit there and judge the actions of the flight crew is non-productive and downright disrespectful!

matt_hooks, I don't agree. Moggiee is correct; the crew should have got it right. I agree that 'we' wern't there, but the accident report goes into great detail about what actually happened.

I accept that, on the day, the holes all lined up, but I'm sure that if you asked the 2 guys concerned they would agree that, as a crew, their performance was somewhat below par. Had this scenario happened during a sim ride I would hope the debrief would have been, at the very least, fairly uncomfortable.

As for judging the actions of flight crew being non-productive, again I disagree. Moggiee doesn't slag them off - and nor do I intend to, but clearly we both feel they could/should have done better, despite the circumstances they found themselves in.

[lomapaseo]

Agree with above. No need to get emotional about the crew part of Kegworth. They were just one part of the causal factors in a lineup of the cheese. Remove any layer and it would only be an incident.

Multiple recommendations followed and the accident was a learning point for the aviation community to adopt.

If there is no blame than there will be less defensiveness and much more likey for all to learn from this combination.

[Zorst]

There's some very dubious analysis in the report on Kegworth.

However, there are several recommendations about training and displays.

I believe it's in this latter respect that the report got it right, and I don't believe that

Their incorrect diagnosis of the problem must, therefore, be attributed to their too rapid reaction...

is substantiated.

Yes, people make mistakes, and designers and airworthiness authorities should allow for those mistakes in their machinations. That's how aviation safety works in the human-controlled environment, and accidents such as Kegworth (and Grammatikos) point to inadequacies in design and training, not in the human being.

http://www.amazon.com/Human-Error-Simon-Bennett/dp/1899287728

[matt_hooks]

I'm sorry but the way I read it, moggiee WAS, as you put it, "slagging the crew off".

And in this case, yes, we can be constructive with our criticism (ok, we missed several clues, so how can we do better?) or destructive (you're stupid, you missed the clues)

As always on these forums it's nigh on impossible to judge the timbre of a post. And I'm sure that moggiee would agree that his post could easily be construed as being negative, rather than an attempt to adress the problem in a constructive manner.

I'm sure we all learned important lessons from coverage and research into the Kegworth accident, but can anyone honestly say that in that situation, with the indications that occurred, they would have made different decisions?

I'd like to hope that I would, with the benefit of having studied that accident, but who really knows?

[moggiee]

With all due respect moggiee, we can ALL have 20/20 (sorry, 6/6) hindsight, but you weren't there on the flightdeck dealing with the emergency.

I'm sure anyone who knows anything about flying knows about Kegworth, and yes, there WERE clues, but the crew were dealing with the situation in a pressured environment and missed them.

They're human, humans make mistakes sometimes!

The design of the cockpit instrumentation iirc was found to have contributed to the accident also.

It was one of those tragic cases where all the holes lined up. For sure we should look at it, and try to learn lessons from it, but to sit there and judge the actions of the flight crew is non-productive and downright disrespectful!

</rant>
To address your points:

I HAVE been there - one night I had a tyre explode in a wheel well, causing a double engine failure (4 jet airliner), loss of 50% of our fuel, failure of the LH hydraulics and structural damage to the fuselage etc. - a MORE pressurised and complex situation than the BMA crew had to deal with. We got it right because we took our time and got the diagnosis right first time.

The Kegworth environment was doubly pressurised because the Captain took control from the FO (changing crew roles at a critical time) and disconnected the autopilot - dramatically increasing his own workload. This meant that he was so overloaded that, by his own admission, he was unable to determine the nature of the failure - thus leaving the diagnosis to the FO. Sadly, the FO was wrong but the Captain had turned the two crew aeroplane into a single crew one and removed the cross-check that is the cornerstone of multi-crew procedures.

The cockpit instrumentation was poorly designed - but there were at least 4 separate indications of engine problems on the LH motor, surely enough for most people? Enough, at least, if you actually take the time to look at them.

In addition to the above, the Captain did not make full use of the cabin crew - in fact he actively discourage the cabin crew from passing the vital info (I know one of the stewardesses on that flight, that piece of info came first hand!). Again, from personal experience I have found that on at least two occasions, one of my cabin crew has given me the final piece of info required to complete an accurate diagnosis.

As for disgracefully slagging off the crew - apart from the input from the stewardess, ALL of the above was said by the AAIB.

Yes the "holes lined up" - but speaking from PERSONAL experience, I know that it is my job to act as safety net when they do so. Not every situation conforms to a nice, neat scenario as practised in the simulator, but that's why pilots and cabin crew are there - to use their experience, knowledge and training to read between the lines and improvise if required.

[twistedenginestarter]

It is amazing that the crew had had zero simulator time on this aircraft type.

[Old Fella]

As my "Pen Name" suggests I am one of the older brigade, however I was involved in multi-engined operations for many years as a Flight Engineer on a variety of aircraft culminating on the B747.

My recollection of reports around the time of the Kegworth accident indicated the crew held a false notion that bleed air from only the No 2 engine was used in the operation of the air conditioning system, a notion which was planted in their minds by incorrect information from a ground instructor during conversion to type. When smoke was apparent, as a result of damage to the No 1 engine, the crew believed the Vibration indications "must" have been relative to the No 2 engine and in haste closed that engine down and at the same time commenced an emergency descent. The fact that the wrong engine had been shut down did not become apparent until the crew endeavoured to spool up the damaged operating engine, all too late in the approach to restart the No 2 engine. This was not the first time, nor will it be the last, that to have "hastened slowly" would have resulted in a better outcome.

[moggiee]

It is amazing that the crew had had zero simulator time on this aircraft type.
Indeed, although they had done a 737-300 type rating (same engines, different instruments).

It's fair to say that BMA (as they were then) badly let down the crew with a second rate training programme - a failing in which the CAA played a part by approving the course.

With regard to the smoke issue - on previous types that the captain had flown, the aircraft fed cabin air from the right hand engine and flight deck from the left. On the 737-400 the two bleed sources are mixed so can no longer be used to determine the source of the smoke and location of the failure.

I have had smoke problems on an aircraft due to a failed compressor and it was very hard to locate the source of the smoke (I saw the smoke in the cabin before I saw the smoke around my knees!) - but engine instrumentation is generally unequivocal.

The reports can be downloaded from the AAIB website and make interesting reading. When used as a case study on MCC/CRM training (and referring to their existing understanding of the chain of events), most students initially feel that the accident was beyond the control of the crew. After evaluating the data in the report, they always (in my experience) come round to the view that the crew rushed the decision making and diversion, mismanaged their own workshare and workload and failed to make full use of their available resources (cabin crew etc.).

This isn't "slagging them off", it's a matter of record and nothing more.

AAIB weblink for reports on this accident:

http://www.aaib.gov.uk/publications/formal_reports/no_4_90_502831.cfm

[Zorst]

When used as a case study on MCC/CRM training (and referring to their existing understanding of the chain of events), most students initially feel that the accident was beyond the control of the crew. After evaluating the data in the report, they always (in my experience) come round to the view that the crew rushed the decision making and diversion, mismanaged their own workshare and workload and failed to make full use of their available resources (cabin crew etc.).


And I suppose that the students in your MCC/CRM training are magically exempt the environmental capture involved in being on the course, and thus don't come round to the conclusion that the crew did not perform well because they know it's what's expected of them in their environment...

Could you demonstrate to us precisely what benefit the industry has derived from CRM and MCC, please?

No? Thought not. No-one can, because it hasn't.

[rogerg]

Zorst
You must be one of those perfect pilots who is too good to gain anything from CRM.
MCC is a licence requirement and for pilots that have never been in a "crew" is a big help to to settling down in the airline environment.

[Zorst]

Not at all, I'm just making the point that no study has ever identified a tangible benefit from all this 'training'.

I've seen some pretty shoddy MCC training, too.

[Tail-take-off]

It is amazing that the crew had had zero simulator time on this aircraft type.

They had infact had exactly the same sim time as any other pilots worldwide on this type as there were precisely zero 737-400 simulators in the world at the time!


It would be impossible to restart the engine if the fire warning handle had been pulled (i think) because the engine bleed sov, fuel sov would have been forced closed.


Wrong. You can push the fire handle back in & it is all restored.

[matt_hooks]

Moggie et al. I happen to agree that the crew, in this instance, took a hasty decision, acting on what turned out to be false information.

And I was always taught that the FIRST thing you do in any emergency situation is sit on your hands, take the time to seek out and assimilate all information before making decisions or acting.

As for the value of MCC training, I think it's one of the great imponderables. It's very difficult to prove a negative (such as that MCC training has no positive effect on safety) but if done properly I can't see how such exposure to the multi crew environment can be harmful.

And Moggiee, I respect that you have direct personal experience of an emergency situation, and that it was handled in a professional manner with a succesful (i.e. safe) outcome. But can you honestly say that you would not be prone to making exactly the same mistakes as the crew at Kegworth did, given the information that they had, and the incorrect technical detail that they had been given? Yes I agree, a more methodical approach might well have led them to identify the problem correctly and avert the tragic outcome, but to second guess their actions is not very productive. To look at them, and learn from them, that is productive, but merely to point the finger of blame less so (I hasten to add that's just my opinion)

[moggiee]

And Moggiee.......can you honestly say that you would not be prone to making exactly the same mistakes as the crew at Kegworth did, given the information that they had, and the incorrect technical detail that they had been given?
Yes I firmly believe that I can - because I was trained to:

1) Not change the roles of the pilots (PF/PNF) in the middle of an emergency,

2) to use engine instrumentation to identify which engine has failed/partially failed rather than intangibles such as smoke and noise and

3) make full use of my cabin crew as eyes and ears down the back.

By recognising the fact that the crew rushed a decision and did NOT make full use of the instrumentation which (for all its design faults) was showing FOUR separate abnormal indications for a problem on the left engine, we can learn that the methodical approach to diagnosis brings a greater chance of a correct diagnosis. This is not pointing the finger of blame so much as identifying causes for the accident.

By the way, as well as the previously mentioned incident I have had 3 other engine failures, one RTO, smoke in the cabin/flightdeck, hydraulic failures, gear problems etc. None of these were mis-identified because we took our time and used the available information to identify the problems. The Kegworth crew used one piece of erroneous information (airconditioning design) in place of FOUR engine indications to identify which engine was giving trouble.

Engine problems should be identified by using engine instruments as a start point, not last resort. It's not that difficult a concept to take on board, I don't think. You only get one chance to "get it right first time".

For the previous posters:

The crew did the "Engine failure and shutdown" checklist because there was no "Fire" and at that time the QRH did not contain a "High Vibration" checklist.

ZORST Re: MCC - yes there ARE tangible benefits. Airlines that I have dealt with have reported lower training costs on type ratings with WELL TRAINED MCC graduates than they experienced before MCC came along. There are bad MCC courses and good MCC courses - just as there are good and bad examples of ALL courses.

Several of my colleagues from the FTO at which I work have moved on from PPL instructing to joining large airlines and feedback from them says that they felt that the MCC course they did gave them a biog leg up (not least because they were already familiar with an SOP that had 95%+ commonality with the one at the airline they joined).

When I did my first multi-crew TR I had no CRM or MCC training - and found that whilst the transition to a 4 jet airliner was a piece of cake on the flying front, the multi-crew relationship was a different kettle of fish. Having seen MCC graduates at work, I can see the benefits.

Still, that's digressing from the point of the thread.

[Old Fella]

It seems "Zorst" has some difficulty in accepting the usefulness of CRM or MCC training with his claim that no study has shown any benefit derived from such training. I cannot argue with his claim, but I certainly am sure that airlines are not going to spend funds on putting crew members through training courses which they cannot see as being worthwhile.

Having had many years as a Flight Engineer in both the Military and Civil environments I can tell you that I have personally experienced the benefits of CRM training. Whilst there may not have been any "study" to show a tangible benefit, and for that we only have the word of Zorst, many investigations into aircraft accidents have shown that had the PIC been willing to use his crew resources, or had not been a "one man band", the outcome would most likely have been different.

The best Captains with whom I flew were those who recognised that those occupying a crew seat had a contribution to make to the safe and efficient operation of any flight. Thankfully, most Captains these days have overcome any tendency to think of themselves as Gods.

[Tee Emm]

[quote]The Kegworth environment was doubly pressurised because the Captain took control from the FO (changing crew roles at a critical time) and disconnected the autopilot - dramatically increasing his own workload. ]

Disagree. Any pilot worth his wings should easily be able to handle an engine failure and hand fly at the same time. Happens all the time in single pilot light twins and they are a damned sight harder to fly on one engine than a jet.

RAF pilots flying Canberra bombers single pilot with no autopilot and in IMC at 45,000 ft handled this sort of situation through normal training and without the benefit of simulators. We didn't see Canberras falling out the sky with engine failures at altitude. It is all about good training. And if todays simulator training places accent on full use of automation then no wonder the automation brigade are so tied up in knots pushing buttons that they forget how to fly an aeroplane - a situation only about to get worse with low hour cadets in the RH seat of jet transports and brought up on a diet of automatics.

By disconnecting the automatics if he chooses, at least the captain can get an immediate feel of the flyability of the aircraft. In the 737 Classic the use of automatics on single engine is quite awkward requiring partial manual flying anyway (manual rudder and trim, no auto-throttle) while carefully "monitoring" the control wheel position in case the rudder is not kept in trim.

Having said that, there is a case for retaining use of the autopilot in such circumstances if the captain feels he is not confident or competent enough to hand fly his aircraft - but what a sad reflection on so called "progressive thinking" on the subject of automation versus pure flying skills. The old story about the pilot who admits he can't fly for nuts but that he can type at 80 words a minute is never so true as an example of todays pilots.

[OzExpat]

Just one question from a dumb colonial. Had the Kegsworth crew responded correctly, would airline safety have ever been improved? Put another way, would we have faced the same problem in a transition, for instance, from the B747-200 to the B747-800?

I'm pretty sure there's no answer to that question but I'll sit back and wait to be educated.

[lomapaseo]

Just one question from a dumb colonial. Had the Kegsworth crew responded correctly, would airline safety have ever been improved? Put another way, would we have faced the same problem in a transition, for instance, from the B747-200 to the B747-800?

I'm pretty sure there's no answer to that question but I'll sit back and wait to be educated.

Ha ..at least this part of the discussion looks forward rather than backwards in hindsight :)

from my study of crew perfomance with engine failures there were many similar muck ups both before and after Kegworth. With all the data plus post event crew interviews I formed the opinion that you can't blame the human for a reaction, but instead have to look at the experience base and training. When you look at those issues you begin to see all the precursors.

Examples: the crew expected engine failures to be overt (lots of noise, vibration, left foot right foot stuff)

The training probably didn't address at that time the deciphering of engine gages in a CRM atmosphere before grabbing a throttle.

Lots has changed since then to address the crew training issues

see also the engine training material on this page http://www.fromtheflightdeck.com/

[Tail-take-off]

Albertz

It has been a long time since I flew the 737 & my memory is getting a little blurred with time but as I recall the fire switch does not disconnect the Generator drive just de-energises the gen through the GCU. As for the Hydraulics it is not possible to physically disconnect the eng driven Hydraulic pump - the fire swich electrically de-activates it. (You would still have the Electric pump in any case). All of the above will be restored by returning the fire switch to normal position.

Of course what you can't do is suck the fire extinguisher agent back into the bottle if it has been discharged:hmm:

[moggiee]

Disagree. Any pilot worth his wings should easily be able to handle an engine failure and hand fly at the same time.
Indeed he should but:

a ) there is no point making life harder than it should be by hand flying when a perfectly serviceable autopilot is available (it's not safer to hand fly, so why do it?),

b ) changing the roles of the two pilots (PF to PNF and vice versa) in the middle of an engine problem also complicates the issue by making the pilots re-jig their mind-sets at a tricky moment.

c ) relying upon the PNF to identify the failure and not checking yourself means that no-one is cross checking. By his own admission the Captain looked at the engine instruments but did not gain from them a clear indication of the problem.

All three of the above go against general UK airline industry practice.
There were a whole pile of other factors associated with the incorrect identification too.

Back in the old days, pilots sat on the outside and got covered in oil and froze - do you want to go back to that idea, too? :). There are no Brownie points or extra money to be had from doing it the hard way.

I would suggest to you that as the Canberra had no autopilot, the average Canberra pilot got a lot more hands on time - but doesn't have to worry about passenger comfort, Passenger safety and can bang out if necessary! How many Canberra crews have died just practising asymmetric flying under controlled conditions? The answer will be a shockingly high number if you work it out. Given a decent autopilot, the late Stn Cdr from Wyton would probably still be alive.

Your argument holds as much water as a collander.

Crews train in the sim to deal with engine failures whilst hand flying - but should use the AP in the air if it's available as it reduces workload. You are clearly NOT and airline pilot as you are out of touch with airline training standards and SOPs.

[moggiee]

And I suppose that the students in your MCC/CRM training are magically exempt the environmental capture involved in being on the course, and thus don't come round to the conclusion that the crew did not perform well because they know it's what's expected of them in their environment...
You clearly didn't understand my post.

The students usually believe that the Kegworth crew were harshly treated by the AAIB - usually because they only have half the story (mostly folklore). Once presented with FACTS they come to their own conclusions - I don't force my opinions on them as that would be bad MCC!

[Zorst]

Not at all, they suffer the environmental capture that your teaching environment intends to subject them to. Quite simple if you think it through...

If CRM works, show me the reduction in the accident rate which tracks the introduction and devlopment of CRM. You can't, because there isn't one, and the movement in the accident rate tracks not this factor, but technology, pure and simple.

[lomapaseo]

If CRM works, show me the reduction in the accident rate which tracks the introduction and devlopment of CRM. You can't, because there isn't one, and the movement in the accident rate tracks not this factor, but technology, pure and simple.

How interesting simple.

I always thought that it simply tracked the inverse of GNP

[moggiee]

If CRM works, show me the reduction in the accident rate which tracks the introduction and devlopment of CRM. You can't, because there isn't one, and the movement in the accident rate tracks not this factor, but technology, pure and simple.
If you care to check the stats from the NTSB, AAIB, NASA, FAA and CAA etc. you will find that (according to those organisations) the percentage of accidents attributed to human factors has remained at around 70-80% for 30 years or so. So, if you look at percentages, CRM has done nothing.

However, look deeper and you will see that the OVERALL accident rate (including Human Factors, Tech, ATC, Weather etc) has dropped by about 50% over the same period.

So, given that information, you can see that the number of accidents caused by human factors over that time has fallen by a half.

I can't be bothered to find you the links - you'll only tell me that the NTSB/AAIB/NASA etc are lying and that you know better.

One last thing - if you fly for an airline, could you tell me which one it is so that I can avoid it in future?

[Zorst]

the OVERALL accident rate (including Human Factors, Tech, ATC, Weather etc) has dropped by about 50%


Yes, it has. This is because of technology. Modern, less risky aircraft, replacing older, riskier, ones, plus the introduction of some specific technology (GPWS being a fine example). There are some fine graphcal analyses of this doing the rounds in the worlds of academia, but as you said: I can't be bothered to find you the links

You also said, quite rightly, CRM has done nothing

[moggiee]

Zorst - please have the decency not to misquote. As you would be clear if you had the courtesy to quote me fully, CRM has not changed the PERCENTAGE of accidents caused by human factors, because the 50% reduction in human factors related accidents has been matched by similar improvements in other areas.

I also said that I couldn't be bothered to find you the links BECAUSE YOU WOULD NOT BELIEVE THE EVIDENCE. I was obviously right.

Your reply clearly indicates that I was right in my assessment of you - you clearly DO believe that you know better than the NTSB, NASA, AAIB etc. You are a classic example of the closed minded, arrogant dinosaur for whom CRM training was invented. Unfortunately, like most of those dinosaurs, you are too closed minded and arrogant to realise that. Enjoy your life in the 1950s.

I sincerely hope that you are a ) not in an airline seat and/or b ) close to retirement age.

The industry does not need people like you.

May I repeat my previous question: if you ARE an airline pilot, please let me know which airline so that I may book my ticket with someone else?

Finally, your misquoting of my post is an example of bad "netiquette" and is the sort of behaviour which is regarded as being discourteous and rude. That does rather prove the point in my favour!

I shall waste no more time on you - you are obviously beyond saving.

[rogerg]

See post 18.

[nojh]

I find it sad that none of you actually know the truth about the lead up to this accident! I was a personal friend of the Kegworth Cpt who crashed and I had actually trained the SFO,highly intelligent on his PPL studies and his twin rating and employed him as a pilots assistant on C404 Data post flights ex Egaa .C404 covered in snow and ice we always got to Luton.Did we ever.

BMA

Training on the A/C B737/400 was absolutely minimal,the Cpt at Kegworth was a Dc9 pilot the F/o flew the Shorts 360,their conversion to the B737,was woefully inadequate.

1179 flight items /circuits was conducted by an Ire/Tre who a long time previous , had been an instructor examiner on the B 707. This man decided that his prior B707 priveledges on the 707 entitled him to the same priveledges on the B 737.He signed their licences,he had no right to do so! Absolutely no right to do so!

The first revenue B737 BMA flight from EMA, was almost cancelled by the CAA,because they suddenly realised the the operating crew were not by CAA standards legally qualified to operate the A/C.

The pandemonioum in the crew room was amazing .Present ,Caa Pilot /CAFU Fcl .Boeing pilots, Bma pilots ,and "HARD RON" the fictitous Ire/Tre. The arguments were horrendous,it was horrible they were all shouting.

The solution/Last minute desperate/solution.

A Boeing pilot would be the Cpt,for the circuits at EMA./1179 items.
Hard Ron would be tested by the Caa pilot sitting on the jump seat.
so that he could legally become an Ire/Tre,on the B 737/400,to sign out his inaugural BMA 737/400 flight revenue earning flight from EMA.
Two hrs later they landed.The Caa /CAFU signed out 'Hard Ron' who signed out the BMA Cpt/Sfo. Oh God what a mess! Boeing pilot said U shure do things different in the UK,sort of cart before the horse!

The Kegworth Crash.

The engine failed on climb out Lhr over Windsor Castle the flight deck wanted to to land back SAP @ LHR,Flight Ops Ema insisted they fly to EMA.that was the start of a crash that killed 70 plus passengers.

Bad PR for BMA if you land at LHR fly to EMA keep it quiet Hard Ron and Sir MByou killed these people,

How do I know I was a BMA PILOT.

Forget the CRM MCC Engineeres and all the rest of you wannabes, the crash was caused by BMA BULLIES

Pilots and CPTS do not make decisions in BMA Head Office Does.

PPS

Hard Ron was banned from flying B707s to USA because he tried to Jump start a 707 three times on the runway .What about the brakes hard RON,
Hard RON was banned from the USA.

Later in my life @ B/ Seattle B757 course/Boeing were so disgusted by Hard Ron and their conduct they were withdrawing the 737 from BMA.

Pratt and Whitney also were with drawing their engines from BMA Dc9 fleet.What a mess.

Kegworth was NOT THE PILOTS FAULT,NOJH WAS A BMA PILOT OH DEAR What a mess.

[Old Fella]

If, as claimed by NOJH, the sequence of events leading to the PIC of the B737-400 involved being endorsed on type is valid the whole "gaggle of geese" involved share the blame. If the type training was "woefully inadequate" the pilots should have stood their ground and insisted on "adequate" training. That said however, at the end of the day the responsibility for the safety of the aircraft and crew is squarely on the shoulders of the Captain.

If the reports which I have read are to be believed, the root cause of the accident was the mis-identification of the engine which had suffered loss of part of a fan blade, which led to the shutting down of the "good" engine by mistake. The reasons why this mis-identification happened may be numerous. The decision as to the most suitable place to land was that of the Captain. There is absolutely no justification for commercial or company reputation considerations over-riding the appropriate safety considerations. Had the correct engine been identified in the first instance and it been shut-down the outcome would, or should, have been vastly different.

[Old Fella]

Windmill starts work fine in a C130, but not so in a B707, as alleged to have been attempted by "Hard" Ron. I heard a similar story supposedly involving a BA B747 at Karachi. Story had it that the crew, some of whom were ex-C130, tried to start a RR RB211 using the "Windmill" method. Trip fuel and pax on board. Failure after three attempts. Resulting in brake burn out with fire. A quick look at the QRH for Airstart would have shown "Airstart at speeds below 250 KIAS will require starter assistance" which would also apply to a "windmill" attempt. The yarn is probably untrue. If anyone knows whether or not this did happen you may care to let me in on the facts.

[fireflybob]

The Boeing QRH then (and now) states that in the event of vibration to retard the thrust lever until the vibration ceases (if necessary to idle). If the vibration continues (highly unlikely at idle) Boeing stated "other engine problems may be indicated".

So, in my opinion, it was procedurally incorrect to shut the engine down in the first place, given that the engine was misidentified.

But like the holes in the proverbially cheese model there were many factors in the Keqworth accident. What about the lack of certification of the engine in that airframe type - engines shouldnt throw blades! But in our business sometimes s**t happens!

It was somewhat ironic that the failure occurred when at height over EMA. If they had been in the cruise on their way to Tenerife over the water and shutdown the wrong engine they would have attempted to stabilise at a lower level, increased the thrust on the offending engine, recognised the error and then had time for a relight on the good engine.

"Mistakes" were made that night but to some extent this accident was a result of the "system" and culture existing at the time.

[lomapaseo]

The Boeing QRH then (and now) states that in the event of vibration to retard the thrust lever until the vibration ceases (if necessary to idle). If the vibration continues (highly unlikely at idle) Boeing stated "other engine problems may be indicated".

So, in my opinion, it was procedurally incorrect to shut the engine down in the first place, given that the engine was misidentified.

But like the holes in the proverbially cheese model there were many factors in the Keqworth accident. What about the lack of certification of the engine in that airframe type - engines shouldnt throw blades! But in our business sometimes s**t happens!


There is a difference between vibration indications which are displayed on a gage within the cockpit and vibration which is suddenly felt in the cockpit. Vibration gages alone are not reliable indicators of an engine malfunction anymore than fire detectors in a cargo hold a reliable indicator of a fire. For a variety of reasons associated with the gage and detection means, false indications are common. Thus it's important to follow recommended procedures regarding the engine to ascertain the extent of the problem before giving up on the engine and turning off not just the thrust but the accessories that go with it.

However step changes in vibration felt through the airframe are genuinely real and as such a scan of the engine gages over several seconds would confirm if a specific engine was involved.

Regarding the cause of the blade failure itself. Engines are not certified not to fail (sorry for the double negative, but that's my point) They are however certified to be able to be shut down safely within a reasonable time frame (like 20-30 secs). I don't recall that there was a shortfall in this regard associated with the Kegworth accident.

[fireflybob]

There is a difference between vibration indications which are displayed on a gage within the cockpit and vibration which is suddenly felt in the cockpit. Vibration gages alone are not reliable indicators of an engine malfunction anymore than fire detectors in a cargo hold a reliable indicator of a fire. For a variety of reasons associated with the gage and detection means, false indications are common. Thus it's important to follow recommended procedures regarding the engine to ascertain the extent of the problem before giving up on the engine and turning off not just the thrust but the accessories that go with it.

lomapaseo, yes I agree. If I recall correctly one of the issues was that the vib indicators on older engines were unreliable (when I was on the B707 I remember the flight engineers saying they were a waste of time!) but the vib indicators on later a/c are much more reliable. This was not covered in training. Obviously all factors should be taken into account before shutting an engine down (easy to say when you are on terra firma but when you are in the hot seat.....)

Regarding the engine certification I recall that the thrust on the engines had been increased but the full certification process had not been applied in this case with respect to that engine being in that a/c. Maybe I recall incorrectly but my basic point is that modern engines shouldnt lose blades and that this was part of the error chain. You could say another part of the chain was the mickey mouse vib guages fitted to the early B737-300s.

[lomapaseo]

Regarding the engine certification I recall that the thrust on the engines had been increased but the full certification process had not been applied in this case with respect to that engine being in that a/c. Maybe I recall incorrectly but my basic point is that modern engines shouldnt lose blades and that this was part of the error chain. You could say another part of the chain was the mickey mouse vib guages fitted to the early B737-300s.

These are kind of softer issues somewhat subjective to one's opinion.

I've already commented on the reliability of things like vibration meters and smoke/fire detectors. We learn to live with them because without them we're even more in the dark.

I believe what you are getting at with the engine installation might be the normal course of growth/design changes within a certified installation and then walking into a new problem.

There is lots of room for argument on both sides. The certification doesn't really prove anything. It does a pretty good job of assessing relative safety. In spite of passing a few hundred test points during certification there are still numerous parts of the perceived acceptable envelope that are not tested until millions of flight hours. The CFM56 engine ran into this and so have lots of other engines. However, the certification of the installation anticipates this by designing tolerance to the blade loss event itself, for whatever reason.

[moggiee]

According to the AAIB report, the was NOT a High Vibration checklist in the QRH, so the crew were in the dark there. It was subsequently added to the book.

[DozyWannabe]

You're also missing another false positive, which was, as I recall, when they shut down the right engine and started their descent, they disconnected the autothrottle, which up until that point had been driving the damaged left engine much harder as it tried to match a thrust setting it could not achieve with the damage sustained. When A/THR was disconnected and the descent started, the thrust setting of the engine was considerably reduced. So in fact the vibration felt through the airframe decreased a great deal, even though they'd shut down the wrong engine.

[icarus5]

Hindsight is a wonderful thing. Many of the training procedures that we are used to today in the UK stem directly from Kegworth. There was no MCC or CRM in those days.
The engines were not air-tested but simply an older one speeded up to give the extra thrust. There had been compressor blade failures before but the crew had not been made aware of them.
They had recieved about 6 hrs "conversion training" and between them had very little experience on the aircraft (less than 100hrs added both together I think).
Pilot jobs were hard to come by and management played on this. A previous pilot had been sacked for diverting in an emergency to the nearest airport rather than contacting base who would have told him to come to EMA.
The culture was such (and in many airlines of the day, not the least BA) was that the cabin and flight deck were separate entities and only the purser was allowed to communicte with the flight deck.
At night being suddenly subject to severe vibrations such that it was almost impossible to read the aircraft instruments, smoke in the cockpit (in previous aircraft associated with the right engine), the vibration guages were the size of a 10p piece (much smaller than other engine instruments and by implication much less important, plus had been notoriously unreliable on the previous aircraft) would have been impossible to read.The aircraft was subject to considerable yawing as the autothrottle kicked in and out (due engine failing),the Captain asked the FO (who also clearly did not know) "which one", the latter replied "Its the Lef..er..Right one". The Captain ordered that one to be brought to flight idle.
When the FO did this, disconnecting the auto-throttle the severe vibration virtually disappeared, the yawing stopped and the smoke disappeared The left engine because the autothrottle was not trying to make maintain max climb power started to appear normal.
How many crews without the hindsight of this accident would have said the right one was the problem since by simply bringing the right engine to flight idle all the symptoms disappeared?
When asked afterwards why did you disconnect the autopilot captain he replied that that was what he had always been ordered to do in his simulator training whenever he had a single engine problem which in those days was exactly true. There are many other points I could make but the above are the most obvious.
Being judgemental, clever,pompous and thinking that you could never have done what these pilots did, given their training, the airline culture and all the other existing circumstances at the time is exactly the attitude that will lead to further accidents. I hope I am wrong.

[moggiee]

Hindsight is a wonderful thing. Many of the training procedures that we are used to today in the UK stem directly from Kegworth. There was no MCC or CRM in those days.
Oh yes there was CRM training - maybe not at BMA (as they were known then) but at other airlines.

United Airlines and many other carriers had been "doing CRM" for 5-10 years and even we in the RAF knew about it.

The bottom line is that, familiar or not with the aeroplane, there were FOUR separate indicators of a fault with the left engine (five if you count the fact that with the autopilot disconnected, the aeroplane rolled and yawed left). If you discount the Vib Gauge that still leaves fluctuating N1 rpm, high EGT and fluctating fuel flow (plus the handling cues).

[DozyWannabe]

If you read the AAIBs report, you'll see some criticism of the engine instrumentation design and layout on the 734.

The EIS for the Boeing 737 was designedto represent a minimum change from the previous hybrid display and, accordingly, it was type certified by both the FAA and theCAA as fit for its purpose. The counters remained identical insize and colour but the dials of all instruments were reducedin size. The pointers were reduced in length by approximately two-thirds and placed on the outsides of the dials but the circumference swept by the needle tips (ie the instrument 'size') remained thesame. The EIS display was deemed to have sufficient communality with the hybrid display to circumvent the need for pilots to be separately rated for EIS-equipped models. It was tested for proper operation, compatibility and freedom from electrical interference but it was not evaluated for its efficiency in imparting informationto pilots.

and

Although there seems to be no question that the EIS display on the Boeing 737 provides accurate and reliable information to the crew, the overall layout of the displays, andthe detailed implications of small LED pointers rather than the larger mechanical ones, and of edge-lit rather than reflective symbology do appear to require further consideration.

This, coupled with the less than satisfactory conversion training, makes the case for flaying the pilots less watertight IMO.

[Double Zero]

OK, I am SLF but from the industry & have done a lot of flying in ( admittedly small ) aircraft, usually as a pro' photographer.

I have always felt that the Kegworth crew were also let down by their PASSENGERS !

That may include cabin crew, someone mentioned an input from a stewardess but I don't know what that refers to, attempting to be helpful or the opposite.

As I understand it, there was a cabin announcement that one engine had a problem, while the people in the cabin, unlike those in the cockpit, could SEE the other one on fire etc.

I was always taught to 'speak up' and this has saved me & the aircraft from nasties a few times, such as un-noticed captions, aircraft on collision course, etc - and that was with extremely experienced pilots, inc. some Test Pilots.

If it is correct that this announcement was made, someone should have spoken up, and quickly ! Better a live berk looking sheepish than sitting like a dumb doomed git...

So I have always felt that the crew were let down by poor instrument layout, and the people behind them.

[Mercenary Pilot]

Didn't a male member of the CC actually try to report what was being seen out of the window but was asked in a very un-PC way to leave the flight deck?

[Double Zero]

If that's the case, that this chap from CC tried to speak up, while I can only imagine the pressure the aircrew were under, my sympathy for them would decline, while that Steward should be commended.

Either way, is it too much to hope that CC are also trained about this situation, using Kegworth as a sad training aid ( like most aircraft accidents ) so that they might help out in any similar situation nowadays ?

Also of course the trend to placing aft-facing cameras for the aircrew would have been relevant here, though whether they cover all engine intakes, jetpipes, control surfaces etc seems unlikely to me - I've been heavily involved in placing remote cameras on the outside of aircraft, often at altitude ( fighters in my case ) and it's not that easy re. very low temperatures, condensation, vibration etc, and certainly not cheap !

A lot cheaper and easier with modern technology and the relatively benign and accommodating characteristics of an airliner though, and I'd say essential - such things may even have saved the Concorde for instance, even if it meant the pilot knew how bad it was and plonked it straight ahead in a field, at least some or indeed a lot of people might well have got out...

Back to the original question, are modern Cabin Crew trained with such a situation in mind ?

[Mercenary Pilot]

are modern Cabin Crew trained with such a situation in mind ?

Yes, its a major part of CRM training.

[icarus5]

Mogiee, the bottom line is that you miss the point. One or two airlines in the UK may have been doing CRM at the time but BMA were not (like the vast majority of companies) and therefore this crew had not had the benefit of such training. As a direct result of Kegworth the CAA later made it mandatory.
Further, when the right thrust lever was retarded (disconnecting the Auto/throttle in the process) all the symptoms all but disappeared. The left engine vibration became minimal because the A/T was not pushing fuel into it trying to speed up the flagging N1. Also the disconcerting yawing immediately ceased for the same reason. The left engine was then also retarded reducing the symptoms almost totally.
Yes the captain grossly added to his workload by handflying and by getting on the other box to find out what the company wanted him to do (where to divert because he feared the sack). The FO was talking to ATC. It took 15 mins from the start to crashing. No time at all to carry out the many duties to prepare for a rapid landing at an unprepared for airfield.
The FO added to the workload by trying to reprogramme the FMS. At no stage did they get a chance to review their decision which given the fact that the major symptoms had disappeared seemed correct.
As to the RAF being aware of CRM I find that a bit of a laugh given their brainwashing of all recruits not to question an order or authority. I have many personal experiences of RAF CRM.

[DozyWannabe]

At no stage did they get a chance to review their decision which given the fact that the major symptoms had disappeared seemed correct.
As it turns out, they did actually try to.

From
http://www.rvs.uni-bielefeld.de/publications/Incidents/DOCS/ComAndRep/Kegworth/AAIB/COPY/gobmerep.htm

Flight deck workload remained high as the first officer obtained details of the actual weather at East Midlands and attempted without success to programme the flight management system to display the landing pattern at East Midlands. This last activity engaged the first officer's attention for 2 minutes. At 2012.28 hrs the commander attempted to review their situation, saying 'NOW WHAT INDICATIONS DID WE ACTUALLY GET (IT) JUST RAPID VIBRATIONS IN THE AEROPLANE - SMOKE ...'. His discussion with the first officer was then interrupted by ATC messages passing a new radar heading, further descent clearance to FL40 and instructions for the aircraft to change radio frequency to East Midlands (Castledon) approach control.
It really just was not their day.

[fireflybob]

It really just was not their day.

DozyWannabe, yes I know what you mean but isn't that was Captaincy is all about?

Human beings all do the best they can in the given circumstances which I am sure is what this crew did. But it seems to be that there was a lack of "problem-solving" on the flight deck. The first step in the solving of any problem is the acquisition of the correct information. Rule I is always maintain safe control of the aeroplane and then if you are not sure what to do sit on your hands and do nothing until you have clearly established what is going on. There are, in my opinion, only a few situations which require immediate action in an aircraft such as rejected take off, GPWS warning, windshear etc.

As has been said before this accident was a benchmark for the industry from which many lessons have (hopefully) been learned.

It took the sinking of the Titanic to get many of the rules for safety at sea which we now enjoy and which must have saved countless lives afterwards.

[DozyWannabe]

There are, in my opinion, only a few situations which require immediate action in an aircraft such as rejected take off, GPWS warning, windshear etc.
I'd say there's one more, which is cabin fire.

From the start of vibration to impact you had some degree of smoke in the cabin and cockpit. Given the horrifying result of even a few seconds' delay at Manchester a few years earlier I think you can forgive them a desire to get back on the ground as soon as possible.

I'm not saying the actions of the crew were perfect, and with 20/20 hindsight it could be argued that they were lacking, but no-one else will ever know what it was like to be in that position at that time.

[moggiee]

As to the RAF being aware of CRM I find that a bit of a laugh given their brainwashing of all recruits not to question an order or authority. I have many personal experiences of RAF CRM.The ignorance of your post shows that you clearly don't have any experience of the RAF - brainwashing is VERY far from the truth.

Command skills and decision making are emphasised to a VERY high degree and CRM training is an integral part of the RAF culture (I speak as a former RAF CRMI).

[FANS]

Can someone clarify what the crew are doing now?

[A2QFI]

All I have been able to find is:-

Captain Hunt was left in a wheelchair & the flight officer won his claim for unfair dismissal. Tells us the immediate outcome but not what is happening now.