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captplaystation
8th Jan 2019, 17:56
https://en.wikipedia.org/wiki/Kegworth_air_disaster https://confessionsofatrolleydolly.com/2015/07/08/angels-of-the-sky-british-midland-flight-092-kegworth-disaster/

er340790
8th Jan 2019, 18:22
Yep - I remember it like yesterday. I'd just left the M1 North that Sunday night heading to nearby Burton-on-Trent, when the news broke on air. My immediate reaction in those post-Lockerbie days was "Oh, Christ! Not another one!" Within minutes, every other vehicle heading east on the (old) A50 was an emergency response vehicle.

As the Trolley Dolly article says, the real tragedy was that most pax were fully aware that the problem was in the Left engine. If in doubt, SPEAK UP!!!

anchorhold
8th Jan 2019, 19:17
Yes, but the primary factor in this accident was the licencing authorities (UK CAA) and the flight operations inspectors (WC) not to require sufficient conversion to the 737-400 instrumentation. Likewise the UK CAA had up to this point delayed the implementation of CRM despite the directive from ICAO, hence the barrier that existed between flight crew and cabin crew.

H Peacock
8th Jan 2019, 19:42
the primary factor in this accident was the licencing authorities (UK CAA) and the flight operations inspectors (WC) not to require sufficient conversion to the 737-400 instrumentaction.

Not convinced: First indication of a snag then the AP was disengaged - PF now loses a huge chunk of diagnosis capacity. Crew then failed to diagnose the correct engine because they rushed into it. Irrespective of the type of engine parameter displays, the fluctuating N1 and ITT would have been there to see if only they'd looked rather than assuming the bleed air was the most important indication. Having wrongly diagnosed they then shut it down!

CRM has gone quite a way since 88, but the flight deckcrew performed badly that evening!

ShyTorque
8th Jan 2019, 19:49
CRM!

Whilst sitting as an ex-RAF jet qualified passenger at a certain American airport in a B737, the captain had just announced his intention to start the engines. At the same time I saw the wind blow a large (probably two by two metre) polythene sheet which had come loose from an adjacent stack of pallets and head straight for the No2 engine intake. I immediately pointed this out to the CC member and advised her to tell the cockpit crew. Instead she made a point of patronising me, telling me that it wasn't an issue and that everything was absolutely normal. Thankfully, it didn't go through the engine, but it could easily have done so, or caused a hot start

On another civilian flight, an RAF colleague and I watched what originally appeared to be a minor oil leak from the number two engine (of another B737) as we flew across the North Sea. The amount of oil suddenly increased until it was streaming out! We soon decided to point this out to the CC. Again, we were patronised and told everything was perfectly normal "They all do that, Sirs!"......("Oh no they don't!"). Our message was not passed to the cockpit.

We were booked on precisely the same airframe for the return flight. It was cancelled because it went tech. We made inquiries why, using the old boys' network. No need to guess which engine had a problem!

captplaystation
8th Jan 2019, 20:05
I was in the Brittania ( ex Orion) sim doing my OCC with BM when it happened. Never forget the Sim engineer telling us that one of our 73's had gone in, and our feeling when we enquired " off the end/ off the side" ? when he replied " no, on the motorway " . My other vivid memory of the time is of the scum calling themselves press who were waiting at the airport the next day as I left to go home , whilst they scurried around trying to catch the grieving relatives arriving from Belfast. The press had a bit more decorum in these days, but I remembered witnessing stuff that really angered me. I knew both the crew from previous encounters, even prior to BM , and they were both just regular line pilots. Most of us at the time were humble enough to admit " there but for the grace of god" , a notable exception being " Hard Ronny" ( bless his soul) , who reckoned " Ow the F***+ could these Boogers have trashed a brand new aircraft" . . . . . Indeed .

LeadSled
8th Jan 2019, 22:58
Most of us at the time were humble enough to admit " there but for the grace of god" , a notable exception being " Hard Ronny" ( bless his soul) , who reckoned " Ow the F***+ could these Boogers have trashed a brand new aircraft" . . . . . Indeed .
A bad day at Exit 24 on the M1.
"Hard Ronny" --- Now there is somebody I remember well --- having once worked for BMA.
As I recall, a major issue in misidentifying the engine was assumptions made as a result of the the smoke in the cockpit ---- an assumption of the source, therefor an assumption of which engine it must be ---- and all that (or didn't, in the case of positive engine identification) followed.
Based on my experience in UK, I always thought it a good example of why "fly the aeroplane" and "follow the checklist" was always more important than "engineer level" detailed knowledge of the aircraft, which was very much the UK approach to tec. courses.
A case of a little knowledge (misapplied) can be dangerous.
Tootle pip!!

blue up
9th Jan 2019, 07:04
Our 737 MAX conversion course was a couple of hours of self-study Powerpoint presentations. Course was presented to us months before the first one was even delivered so not all that much has changed in 30 years.

1066
9th Jan 2019, 10:07
Thanks blue up! I was ready to make the same point. I think common type ratings extended by CBT still warrant more examination post Lion Air.
I remember a standby callout to operate an IAE engined 320 for the first time from LGW. My base only operated CFM 319/320s. Fortunately I had the notes in my bag and it was a hour plus taxi ride so I had a bit of time to refresh my very limited knowledge.
Again it was fortunate that the FO, being LGW based, was familiar with the IAE engine.
"OK first sector is yours and talk to me all about the engine while you are using it".
All went well but not an ideal situation especially if the FO had been new with no IAE experience. I can't remember if crewing had access to who was and who wasn't IAE experienced. On paper all crews were IAE qualified!
1066

HEATHROW DIRECTOR
9th Jan 2019, 12:20
Shytorque When I worked abroad a Comet was taxying out and we watched in amazement as a main wheel came off and rolled across the grass. We told the crew and it taxied back to stand. We later heard from a pax that he had seen it and told the cabin crew to tell the pilots: "It's OK, sir, quite normal!" Bizarre,eh?

Akrapovic
9th Jan 2019, 15:28
Yes, but the primary factor in this accident was the licencing authorities (UK CAA) and the flight operations inspectors (WC) not to require sufficient conversion to the 737-400 instrumentation. Likewise the UK CAA had up to this point delayed the implementation of CRM despite the directive from ICAO, hence the barrier that existed between flight crew and cabin crew.

Primary factor?

DHC4
9th Jan 2019, 15:39
I remember a few months after the crash talking to one of the line techs, he said that one of the engines had high vibs and they recommend an engine change. This was overruled and the aircraft flew.

DaveReidUK
9th Jan 2019, 16:10
Yes, but the primary factor in this accident was the licencing authorities (UK CAA) and the flight operations inspectors (WC) not to require sufficient conversion to the 737-400 instrumentation. Likewise the UK CAA had up to this point delayed the implementation of CRM despite the directive from ICAO, hence the barrier that existed between flight crew and cabin crew.



https://cimg6.ibsrv.net/gimg/pprune.org-vbulletin/745x633/g_obme_cause_statement_66553ed923bae55c813bd0878201d38fdfb69 f89.jpg

old,not bold
9th Jan 2019, 17:16
I remember a few months after the crash talking to one of the line techs, he said that one of the engines had high vibs and they recommend an engine change. This was overruled and the aircraft flew.


Q1. Would the vibration be a warning of possible fan blade fracture? I have no idea, but if not it's not relevant.

Q2. If the "Line Tech", presumably a certifying engineer, really thought that the engine should be changed before another flight, he or she only had to refuse to release the aircraft to service, giving full reasons. If he or she doesn't think that, then the aircraft can be released. What the "Line Tech" really should not do is release it to service, then mutter after the disaster that "I told you so". So I'm wondering who "over-ruled" whom in the story you heard from the "Line Tech", and who actually released it to service.

Edit:

Re Q1; here's what Wiki says, which I missed.......

The inquiry attributed the blade fracture to metal fatigue, caused by heavy vibration in the newly upgraded engines, which had been tested only in the laboratory and not under representative flight conditions..
So that's the answer to Q1. I suppose a better answer is that any heavy vibration could have serious consequences in all sorts of ways, just one of which might be a blade fracture.

old,not bold
9th Jan 2019, 17:44
DHC4 I was intrigued by your post, and went back to the AAIB report to refresh my memory. Page 22 is relevant;

https://cimg1.ibsrv.net/gimg/pprune.org-vbulletin/636x306/screen_shot_01_09_19_at_06_35_pm_1a2531bea2b279296a195ebc060 9be2048131345.png

"No further comments" disagrees with what you were told.

Mr Angry from Purley
9th Jan 2019, 17:48
Yes, but the primary factor in this accident was the licencing authorities (UK CAA) and the flight operations inspectors (WC) not to require sufficient conversion to the 737-400 instrumentation. Likewise the UK CAA had up to this point delayed the implementation of CRM despite the directive from ICAO, hence the barrier that existed between flight crew and cabin crew.

Anchor
I'm not sure it was a primary factor for sure one of the swiss cheese holes absolutely. I saw the aircraft coming down as it went past the Church in Kegworth. I was convinced it was an ATP (the BM flight from LHR came in at the same time). The wife vividly remembers the flames, with my dodgy eyesight I can still remember the horrible clanking noise from the stricken engine (thus why i thought it was the ATP)

DaveReidUK
9th Jan 2019, 18:06
I remember a few months after the crash talking to one of the line techs, he said that one of the engines had high vibs and they recommend an engine change. This was overruled and the aircraft flew.

The only reference in the investigation report to previous engine vibration issues relates to No 2 engine (the one that was performing perfectly during the accident flight and was shut down in error).

tdracer
9th Jan 2019, 18:45
Edit:

Re Q1; here's what Wiki says, which I missed.......


So that's the answer to Q1. I suppose a better answer is that any heavy vibration could have serious consequences in all sorts of ways, just one of which might be a blade fracture.

As is often the case, Wiki is over simplistic. The problem was that the newly approved higher thrust rating could cause the fan blades to go into flutter (commonly known as simply 'fan flutter'). Once fan flutter starts, the fan blades can fail in just a few seconds.
The industry learned a great deal about fan flutter in the aftermath of this accident. Now days, specific testing is performed on new or significantly changed fan blades to look for signs of fan flutter before the engine is certified.

MichaelKPIT
9th Jan 2019, 18:51
As the Trolley Dolly article says, the real tragedy was that most pax were fully aware that the problem was in the Left engine. If in doubt, SPEAK UP!!!

Yes but for a lot of them their fears were allayed when they were told "we've shut down the right engine." Well yes, they'd shut down the right (hand) engine, but not the right (correct) engine!

Discorde
11th Jan 2019, 18:07
Yes but for a lot of them their fears were allayed when they were told "we've shut down the right engine." Well yes, they'd shut down the right (hand) engine, but not the right (correct) engine!

Years ago I was among a group of trainers who suggested to our managers that we should refer to 'engine 1' and 'engine 2' rather than 'left' and 'right' to remove this uncertainty. The numerical designation also removes the ambiguity arising from observers facing forward or aft. Nothing came of our input.

DaveReidUK
11th Jan 2019, 20:13
Years ago I was among a group of trainers who suggested to our managers that we should refer to 'engine 1' and 'engine 2' rather than 'left' and 'right' to remove this uncertainty. The numerical designation also removes the ambiguity arising from observers facing forward or aft. Nothing came of our input.

Isn't that the terminology that's been used since the year dot? And for 4-engined aircraft there is little alternative.

svhar
11th Jan 2019, 21:38
For pilots. Not cabin crew and passengers.

H Peacock
11th Jan 2019, 23:01
Engine identification depends upon the aircraft manufacturer. Bombardier appear to go for left and right as opposed to 1 and 2.

Discorde
12th Jan 2019, 01:58
Isn't that the terminology that's been used since the year dot?


The annotation depended on customer choice. On Britannia Airways B757/767s the fuel control switches and engine fire switches were labelled 'L' and 'R'. Ditto EICAS messages:

https://cimg8.ibsrv.net/gimg/pprune.org-vbulletin/546x326/b767_qrh_eng_fire_edd4a51c5f0beba1419bf49bf5935bec2c70378b.j pg

excrab
12th Jan 2019, 06:53
Donít really know if the cabin crew on a 737 would get confused about left and right. The doors are numbered L1 R1 etc, but donít think they get confused if they happen to be looking backwards instead of forwards.

DaveReidUK
12th Jan 2019, 08:37
Donít really know if the cabin crew on a 737 would get confused about left and right.

That wasn't relevant on BD92 as the cabin crew reportedly didn't hear the commander's announcement about the engine being shut down.

The announcement itself was unambiguous, referring to "trouble with the right engine ... which was now shut down", and heard by many of the passengers who had been observing signs of fire from the LH engine, but nobody brought the discrepancy to the cabin crew's attention.

rog747
12th Jan 2019, 08:52
I was always under the impression at least 2 of the cabin crew including an FSM Ali Osman heard the skippers announcement but it was not their remit (nor in their training) to trouble the flight deck again as it was assumed they (the FD) knew what they were doing and they were diverting to EMA (not an emergency landing, as far as pax and cabin crew were concerned)

DaveReidUK
12th Jan 2019, 09:58
I was always under the impression at least 2 of the cabin crew including an FSM Ali Osman heard the skippers announcement but it was not their remit (nor in their training) to trouble the flight deck again as it was assumed they (the FD) knew what they were doing and they were diverting to EMA (not an emergency landing, as far as pax and cabin crew were concerned)

Yes, to clarify - there were 6 cabin crew. The 3 in the aft cabin all observed the signs of distress from the left engine, but none of those 3 heard the announcement about the right engine having been shut down. Some or all of the other three cabin crew members presumably did hear the shutdown announcement, but it's not clear from the report whether any of them had seen the flames. Either way, as you rightly say, the pilots were not informed by the CC that there were continuing issues with the remaining live engine.

STUF
12th Jan 2019, 11:44
My wife was a flight supervisor/purser with Midland at the time and shared a house with the flight supervisor on the BD92. About six months later, Midland had an identical issue with a B737-400 on the same route. On this occasion, my wife was the senior cabin crew member on board and she went into the FD and pointed at the side she had seen flames/sparks coming from, rather than say L or R, 1 or 2. The aircraft subsequently diverted to EMA and the CC were then required to operate on a DC9 to take the pax across to BFS!

rog747
12th Jan 2019, 11:54
Yes Dave, back then it was in no one's remit, nor in the FOM/SOP/SEP nor CC manuals to go tell the FD something like that...

Capt Kevin Hunt was a approachable man and pragmatic too.
I did not know any of the CC nor the FO but Kevin was a really kind and lovely man who I had known and worked with for many years since 1977 - he was not rostered that flight (BD92) but stepped in to swap with a colleague who wanted the Sunday off.

I'm ex BMA LHR D/O as you may know - At our LHR reunion (class of 77/78) 2 years ago in 2016 the talk then still was very much about BD92.
Many of my old ground colleagues worked with EPIC and for many months after with all the relatives and survivors - a harrowing time and task for all at the Heathrow Care centre and BD emergency response - They were terrible hours days and weeks- life defining for all involved and all were affected.

After a day in Epic, My pal who was supervisor of BD LHR baggage services was despatched to Donington to meet up with the Police who took him to their Training HQ. - shown to a Gym which was full of belongings and luggage that was being brought in from the crash site. One by one he went through every item including coats and handbags, the personal belongings in the handbags made it desperately real and sad and for 5 days he worked with relatives and Police to repatriate belongings. To this day he will struggle with the simple request to get something out of a handbag and will never forget the smell of damp muddy belongings and aviation fuel.
Over the following weeks he would meet some of the relatives as they passed thru the Heathrow care center run by my colleagues and again at the Memorial Service held in Belfast which is his hometown.
Now we go back to those weeks in January 89 when all did the best they could to make things better. They all cared at the time and still do.

I remember talking to the traffic officer/flight dispatcher about the flight a few years later, I think he re-trained to work in air traffic control/Tower?
His stories about accepting late passengers at the gate as we did back then (LRP's/LMC's) on that evening, made my hairs stand on end.

I also knew the handling agent at Tenerife in 1977 (He handled us too there) who found the last 4 late pax (Mum Dad and 2 kids) for the KLM 747 that were missing and wandering in the terminal and he rushed them out to re-board the Jumbo for Las Palmas...

Midland Alpha9
14th Jan 2019, 10:58
Kevin Hunt was a decent kind man and a very approachable pilot as Rog describes. Whilst he was in Stoke Mandeville recovering from his serious spinal injuries one of our BMA Heathrow colleagues was knocked off his motorbike by a car on the Heathrow Spur road. Sadly the person incurred the same result as Kevin, serious spinal injuries which left him unable to walk. I asked Kevin if he would be kind enough to chat to the young man, who was in Stoke Mandeville at the same time. Kevin being Kevin didn't hesitate and met up with the young lad.
Yes Kevin made a costly mistake that fateful night but he was a lovely human being. RIP my old friend.

condor17
16th Jan 2019, 10:01
We cannot change what happened on the day . But thank you all those professionals , who did it right afterwards. For your professionalism , backbone and compassion .

rgds condor .

Wally777
16th Jan 2019, 11:05
I had met Kevin once before over a beer in Glasgow. Certainly a likable gentleman. That night my mother a warden for old folk in Kegworth phoned me in tears. She had heard a plane crash. I was a member of BALPA AIG and then an F/O with Orion in my final month before moving on. I grabbed my jacket and headed to the airport. Orion Ops told me it was a BMI B737. The police let me through their roadblock as I had an ID stating my role with BALPA. I guess I was on the scene about 15 minutes after the accident. I walked down the right-hand side of the aircraft, found the nose gear in the centre of the motorway and then worked my way up the left-hand side. I ended up working at door 1L for probably the next three hours helping get the remaining survivors off. More importantly, I watched Kevin being slowly cut out and removed from the flight deck. Not a night I shall forget.

Tankertrashnav
16th Jan 2019, 23:24
I have always wondered how many of those killed would have survived the impact if they had been sitting in rearward facing seats. Having spent a couple of thousand hours flying facing aft, both as pax in RAF passenger aircraft which all had rearward facing seats, and down the back of a Victor, I have never felt the slightest discomfort flying that way. Indeed for several years after I left the service, flying facing forward as a passenger seemed distinctly odd to me. I am 99% certain that there is no chance that civil airlines will ever adopt rear facing seats as a policy - it would be a brave maker/operator to be the first to make such a decision, but I think it's a pity. I remember a book on aircraft crashes called "It Doesn't Matter Where You Sit", and that is probably true for the majority of accidents, but there will always be some, like this one, where the direction you are facing could mean the difference between life and death.

tdracer
17th Jan 2019, 00:09
The 16g seat standard would have made far more difference than aft facing seats - aft facing doesn't help much when the seats collapse on each other.
In fact, if I recall correctly, this was one of the accidents that lead to the 16g seat standard.