M6 Kegworth on BBC News

[joy ride]

This morning I saw a BBC TV news feature on this accident and what lessons have been learned from it, quite an interesting feature too, so well done the Beeb. Not sure if it is being repeated throughout the day but glad to have seen it; marking the 25th anniversary in 4 days.

Kegworth air disaster - Wikipedia, the free encyclopedia (http://en.wikipedia.org/wiki/Kegworth_air_disaster)

[crewmeal]

M6? you surely mean the M1.

[joy ride]

Oops! Yup, M1.

[Mr Angry from Purley]

Can still recall vividly the noise and flames as she came past the Church in Kegworth.
I'm sure lessons learned, 25 years on what would be different?
1. If it happened again, the chances as they were 25 years ago, of no motorway traffic being involved on a busy sunday night....Miracle
2. Now the internet would be full of u tube pics of the incident
3. Someone would mention fatigue.
:\

[Shaggy Sheep Driver]

IIRC that bit of the M1 has since been considerably remodeled and re-landscaped since the accident. Back then the motorway was in quite a deep a cutting which I think has since been opened out. The aircraft largely impacted into the western side of that cutting.

[joy ride]

One lesson the BBC report mentioned was the brace position, particularly legs, as several leg injuries were caused in the crash by being trapped beneath seats.

[rog747]

perhaps you could kindly please edit your post heading to M1...iso M6

do you have a link please to today's BBC news clip i cannot find it thanks.

we are coming up to the 25th anniversary of the crash - a grim month 25 years ago as we had the Clapham junction train crash and Lockerbie just before the BMA crash.

i worked for BMA for many years and Capt Kevin Hunt was a good friend at work.
and many of my ground staff colleagues at BMA LHR worked tirelessly with the families of the killed and injured for along time after the accident.

[DaveReidUK]

BBC article here from the 20th anniversary five years ago:

BBC - Derby - History - Kegworth: Twenty Years On (http://www.bbc.co.uk/derby/content/articles/2009/01/07/kegworth_20_years_feature.shtml)

[rog747]

davereid many thanks indeed -
yes i saw that one but missed today's BBC feature...

a poster above said fatigue was/could be implicated - i do not think that was an issue with Kegworth? or i have missed something?

what can be gleaned from the accident 25 years on?
in no particular order

training implications from analogue style cockpit to new glass cockpit
Cabin Crew and CRM
seat strengths and crash worthiness
brace positions
engine manufacture and certification standards

[joy ride]

First post edited, M6 changed to M1, apologies!
I cannot find any link to yesterday's report. The TV was on in the background while I was working and I did not hear much of it.
Thanks for that link Dave.
A sad accident, regardless of cause and effect they so nearly made it.

[Coochycool]

Briefly caught the same clip and what shocked me was the report that Kegworth was actually Britains last air passenger fatality. Immediately had to ask myself in quite some shock, can that be true? Stand to be corrected but even if its close, speaks volumes for the lessons learned and how far we've come since.

Waiting to be corrected but strikes me as quite an achievement

[Phileas Fogg]

Knight Air @ LBA 1995

[DaveReidUK]

Knight Air @ LBA 1995The Knight Air Bandeirante crash involved the last UK fixed-wing passenger fatalities.

It's less than 6 months since the last helicopter passenger fatalities:

Air Accidents Investigation: S6/2013 AS332 L2 Super Puma, G-WNSB (http://www.aaib.gov.uk/publications/bulletins/october_2013/s6_2013_as332_l2_super_puma__g_wnsb.cfm)

[Davidsoffice]

Does the Manx2 crash at Cork not count? British 'airline', Northern Irish origin 10 Feb 2011. Fatalities.

David

[WHBM]

One of the issues from Kegworth was passengers understanding how to evacuate, and shortly afterwards British Midland (as they were then) changed their pax briefing at the start of each flight to emphasise the floor level escape route lighting, pax were told about this and then Look Now To See, and the lighting was switched on/off for a moment to show what it looked like illuminated. I believe there was an electrical mod made to their aircraft to enable this to be done straightforwardly from the briefing position. It was a British Midland thing you didn't see elsewhere.

About 10 years later, new world, new, reworded safety briefing, and that emphasised bit disappeared again. I do sometimes wonder why it is that SOME of the lessons learned from incidents get forgotten by subsequent generations of safety engineers.

I've seen exactly the same on roads, additional warning signage erected at a particular accident point, after 10 years or more without a repetition it then all gets removed down to the standard spec again.

[Sir George Cayley]

In September 1999 G-BYAG a Britannia 757 crashed on landing at Girona Airport, Spain. Although all pax and crew escaped the wreckage (some with serious injuries) one man died the following day.

I've seen reports that indicate an underlying medical condition was responsible and that that the crash had brought on his untimely end.

If this is true than one could say that was the last fatal accident involving British pax on a UK airliner.

SGC

[A30yoyo]

The Wikipedia page says: .....'It was later found that all 737-400's had the fire warning lights cross-wired'......if so how was it pilot error?

[WHBM]

The Wikipedia page says: .....'It was later found that all 737-400's had the fire warning lights cross-wired'......if so how was it pilot error?
I'm sure that was a misbelief, even though it was suspected in the days after the accident until proved not so. It even penetrated to the 757 as well. I recall a BBC TV news item a couple of days after the accident where they went to Luton and Monarch engineers were putting the Avometer on every file warning circuit in the fleet to check them.

[DaveReidUK]

if so how was it pilot error?The AAIB identified 5 factors contributing to the shutdown of the wrong engine. Of these, 3 were beyond the immediate control of the pilots.

The remaining two were:

They reacted to the initial engine problem prematurely and in a way that was contrary to their training.

They did not assimilate the indications on the engine instrument display before they throttled back the No 2 engine.

[DaveReidUK]

I'm sure that was a misbelief, even though it was suspected in the days after the accident until proved not so.Correct. From the accident investigation report:

"No evidence was found of any cross-connection or similar obvious wiring errors associated with either the engine instrument system (EIS) or the fire detection system".

[A30yoyo]

I've corrected that line in the Wikipedia page and added a link to the AAIB report which is also referenced at the page bottom.
Have there been changes in engine-out landing approaches for twins since Kegworth (steeper 'flaps-15' approaches for example)? Was covering the M1 with a slab in line with East Midlands runway considered?

[DaveReidUK]

Was covering the M1 with a slab in line with East Midlands runway considered?No major roads under the final approach to an airport? That would create an interesting precedent, and it would certainly rescue the civil engineering industry from the doldrums. :O

A30 at Heathrow, M8/9 at Edinburgh, A79 at Prestwick, M23 at Gatwick (and the railway line too, presumably), etc, etc ...

[A30yoyo]

Yes, I suppose slabbing over the MI 'ditch' would be 'creating a precedent' in the minds of the bureaucrats . What about low-power steeper approaches with one engine inoperative?

[Herod]

I think a lot was learnt from that accident. Several years ago I had to shut down an engine on a 737 because of low oil pressure. During the subsequent diversion to the "nearest suitable" I checked with the FO several times "Which engine was the warning associated with? Which engine have we shut down?"

[A30yoyo]

Are the cabin crew and passengers ever included in CRM diagnostic thinking/double checking (assuming there's time) when an incident occurs which the crew can't see (engines, rear of aircraft)?

[Wander00]

ISTR a former RAFAT Manager, R.. T........e, by then also a former airline captain, spent a fair bit of time on TV, explaining the differences between glass and analogue instruments

[ancientaviator62]

A30yoyo,
not long after the Kegworth crash we had an engine fire on take off on a C130K. I was the ALM and reported this to the Captain but there were no indications on the gauges of a problem. As I was by then very experienced on the Herc he took my word for it shut the engine down and landed overweight.We were carrying a load of ammo so it may have concentrated the mind! During the write up he actually referred to the Kegworth incident and how if the cabin crew had been involved the outcome may well have been different.
So your point is well made.

[rog747]

if only one of the cabin crew had popped in the flight deck and said Skipper the left one is throwing out tin cans and sparks ....BBC Radio Leicester - Jim Davis, Kegworth - 25 years on (http://www.bbc.co.uk/programmes/p01nh2x2) new programme - last 60 minutes of show

[captplaystation]

I knew both Kevin & Dave prior to joining Midland (Kevin from meeting him in the Glasgow Flying Club bar on his GLA nightstops /Dave from my Flying Instructor course which he completed at the same time ) which only went to reinforce the "it could have happened to anybody" feeling. They were both average line pilots, contrary to the public slagging they took from the AIB engineering inspector, & later BM's chief pilot & various directors. The funny handshake guys stuck together to make sure as much blame as needed was put their way, and the other factors were suitably diluted.

I was in the Orion/Brit Sim at EMA when it happened, on my 737 TR Conversion, & will never forget being greeted at the end of the session by the Sim Ginger Beer "One of your 73's has gone in up at the airport" / "where, off the side ? off the end ?" / "No, on the bloody motorway !" . . .we were shell-shocked.
My significant other knew I was on my TR & probably knew I was only at the Sim stage, but, pre mobile phones I remember the telephone lines being totally overwhelmed & being unable to call home till next day.

I positioned home the next day & had to witness the sight of the arriving relatives on a special flt from BFS being mobbed by the baying press. I think my nature was a bit softer in these days,as, in the same situation today, Nikons would be inserted where they were never designed to go . . . journalistic scum.

It has formed the centre piece of more CRM courses than I care to remember, and has indeed been "done to death", but many valuable lessons were learned.

Tragic, and could have so easily been repeated just afterwards a few junctions further down the M1 when BM launched another 73 out of EMA (to eventually arrive in Luton sharpish) with no seals on oil chip detectors. . .that was a close one.

I don't know what happened to the guys, last I heard Kevin was not too well & he & his erstwhile partner were no longer an item, think Dave has no involvement in aviation, but I stand to be corrected on both points.

Sympathies to those still suffering in one form or another 25 years on.

[strake]

Often, Pprune responses to incidents (of varying severity) degenerate into arguments and postulations about how passengers behaved and their comments afterwards. I found some of the personal experiences quoted in the article below quite profound. From those who realised something was amiss ie, the baker who noticed the engine failure mentioned by the captain was referring to the wrong engine, to those whose lives were irreversibly transformed by the horror of the experience and who still suffer today.
Maybe some of the armchair 'pilots and passengers' posting here (who I accept may never have been near an aircraft) will think of this the next time they are ready to scoff at a report of an emergency landing or depressurization.

BBC News - Kegworth air disaster: Plane crash survivors' stories (http://www.bbc.co.uk/news/uk-england-leicestershire-25548016)

[rog747]

thanks for your nice response

the radio programme today had a short interview with MB and he said Kevin died 6-9 months ago
I had lost touch so was saddened to hear this today

BBC Radio Leicester - Jim Davis, Kegworth - 25 years on (http://www.bbc.co.uk/programmes/p01nh2x2)

New documentary about the accident go to last 60 minutes

[A30yoyo]

ancientaviator62

Well your Hercules initiative may have contributed to your making it to ancientaviator status.....does current CRMthink include the Captain or his messenger pro-actively going back and asking the passengers and/or cabin crew 'what they saw' (given the luxury of time) when the incident could not be seen from the cockpit? (Aviate, Navigate, Communicate, Investigate?)

[captplaystation]

rog747

Sad to hear that, I am guessing he wasn't exactly cherishing the date looming on the horizon. He never came across as bitter on the couple of times I met him afterwards, more an inner sadness that he felt other aspects had been ignored in the rush to behead a scapegoat.

I guess we should remain happy for him he survived that long ,given the extent of his injuries, although his quality of life subsequently was not the best.



Edited to say, this from another forum


May 18, 12, 4:30 pm
Unfortunately Kevin's funeral was today.
The bit of the investigation which didn't get highlighted was "What was the conversion training for the pilots for 737-300 to 737-400 at that time and why did it change so dramatically afterwards?

[Innominate]

I recently went to a lecture by a researcher in Human Factors, who used Kegworth as one of his examples.

IIRC he mentioned that the conversion training for the new 737s was poor, and didn't emphasise that the air supplied to the cockpit and cabin came from the engine on the opposite side to the one used in early models of 737. This meant that when the pilots smelled smoke they assumed it was coming from the "other" engine, which they duly shut down.

In addition, the policy at the time was that cabin crew should not distract the pilots in an emergency, so the information from the pax was not passed on.

[Wander00]

CPS & innominate - that's what I recall R.. T..........e saying on TV at the time

[Cricket23]

out of interest (maybe) I used to work with someone who was on that flight. The person had a very 'devil may care' attitude and didn't get stressed too much. Over a few beers one day he said that he was on the Kegworth flight, but as he hated flying he got tanked up before take off.

As he staggered to his seat he was asked by a couple of girls if he would change seats. He didn't mind and plonked himself down. In his drunken stupor he says that he vaguely recalls 'a real commotion' in the cabin, and then nothing ........for weeks.

Apparently, he was in coma and eventually came round. In the meantime, his family thought he was dead as the girl he changed seats with died in the crash.

From that day he treated each day as a bonus, hence his very relaxed attitude?

Regards,

C23

[4Greens]

The pax seats should be fitted facing towards the tail.

[Herod]

4Greens, have to agree with you. RAF transport aircraft were all fitted that way (still are?), and research has shown that it improves survivability considerably. However, we're in the chicken/egg situation where no manufacturer will produce them because of public perception, and the public don't know because no aircraft are fitted that way.

[A30yoyo]

A swift search on Pprune 'rear facing seats' brings up (amongst other threads)
http://www.pprune.org/aviation-history-nostalgia/328995-identity-airliner-stairs-under-tail.html
which suggests rear facing seats expose passengers more to flying debris in a hard deceleration but also gives a few examples of airliners which had at least partial rear facing seats (Trident, BAC 1-11) and mentions BUA BAC1-11s on military charters with all rear-facing seats