British Midland Kegworth Crash on T.V Tonight
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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.
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.
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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!
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!
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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")!
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")!
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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.
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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.
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.
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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
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
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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.
It's my understanding that the words "contrary to training" were inserted in the report after the CAA made representations.
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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 )
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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
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
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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.
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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.
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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.
"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.
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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.
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"Take-off is optional, Landing is mandatory"
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.
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"Take-off is optional, Landing is mandatory"
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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.
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We will do the drill according to the amendments to the amendments I er think?
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.
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We will do the drill according to the amendments to the amendments I er think?
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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).]
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).]
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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.
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.
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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.
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.