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-   -   30 yrs ago today (https://www.pprune.org/rumours-news/617048-30-yrs-ago-today.html)

captplaystation 8th Jan 2019 17:56

30 yrs ago today
 
https://en.wikipedia.org/wiki/Kegworth_air_disaster https://confessionsofatrolleydolly.c...orth-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


Originally Posted by captplaystation (Post 10355433)
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


Originally Posted by anchorhold (Post 10355374)
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


Originally Posted by anchorhold (Post 10355374)
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....8fdfb69f89.jpg

old,not bold 9th Jan 2019 17:16


Originally Posted by DHC4 (Post 10356152)
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....2048131345.png

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

Mr Angry from Purley 9th Jan 2019 17:48


Originally Posted by anchorhold (Post 10355374)
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


Originally Posted by DHC4 (Post 10356152)
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


Originally Posted by old,not bold (Post 10356227)
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


Originally Posted by er340790 (Post 10355307)
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


Originally Posted by MichaelKPIT (Post 10356317)
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.


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