Kegworth
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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.
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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.
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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.
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.
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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).
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If you read the AAIBs report, you'll see some criticism of the engine instrumentation design and layout on the 734.
and
This, coupled with the less than satisfactory conversion training, makes the case for flaying the pilots less watertight IMO.
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.
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.
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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.
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.
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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 ?
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 ?
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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.
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.
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At no stage did they get a chance to review their decision which given the fact that the major symptoms had disappeared seemed correct.
From
http://www.rvs.uni-bielefeld.de/publ...Y/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.
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.
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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.
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.
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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).
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What are the Kegworth crew doing now?
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.
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.
