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Kegworth

Old 29th Feb 2008, 07:12
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Kegworth

There was an interesting new Seconds from Disaster the other night. It appeared the co-pilot tried to re-start the good (right) engine but there was insufficient forward speed to get it going. I note however that the APU was started when the engine was first shut down. It looks to me as though on the 737-400 you can only use the APU to start the left engine. Is this the case, and if so what's the logic in that?
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Old 29th Feb 2008, 11:29
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From the AAIB report (pages 104/105); at the time of the accident the Quick Reference Handbook gave a procedure suitable only for the restart of the No 1 engine (using APU bleed air) and such an attempt to start No 2 would have required improvisation. The report goes on to say that this check list was subsequently amended to cover the restart of either engine.
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Old 29th Feb 2008, 12:36
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That suggests the APU is only connected to one engine. Why would that be? What was the solution now in place?
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Old 29th Feb 2008, 16:52
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The APU is connected to the left side of the aircraft (the same side as engine No 1). To use APU bleed to start engine No 2 you need to open the isolation valve which then allows bleed air from the left side to feed the right side.
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Old 29th Feb 2008, 23:14
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Of course, correctly identifying the failed engine in the first place would have avoided the problem. Given that the FDR showed "marked fluctuations in N1 speed, high EGT and low, fluctuating fuel flow" on the left engine that should not have been difficult.
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Old 1st Mar 2008, 23:43
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With all due respect moggiee, we can ALL have 20/20 (sorry, 6/6) hindsight, but you weren't there on the flightdeck dealing with the emergency.

I'm sure anyone who knows anything about flying knows about Kegworth, and yes, there WERE clues, but the crew were dealing with the situation in a pressured environment and missed them.

They're human, humans make mistakes sometimes!

The design of the cockpit instrumentation iirc was found to have contributed to the accident also.

It was one of those tragic cases where all the holes lined up. For sure we should look at it, and try to learn lessons from it, but to sit there and judge the actions of the flight crew is non-productive and downright disrespectful!

</rant>
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Old 2nd Mar 2008, 18:43
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It was one of those tragic cases where all the holes lined up. For sure we should look at it, and try to learn lessons from it, but to sit there and judge the actions of the flight crew is non-productive and downright disrespectful!
matt_hooks, I don't agree. Moggiee is correct; the crew should have got it right. I agree that 'we' wern't there, but the accident report goes into great detail about what actually happened.

I accept that, on the day, the holes all lined up, but I'm sure that if you asked the 2 guys concerned they would agree that, as a crew, their performance was somewhat below par. Had this scenario happened during a sim ride I would hope the debrief would have been, at the very least, fairly uncomfortable.

As for judging the actions of flight crew being non-productive, again I disagree. Moggiee doesn't slag them off - and nor do I intend to, but clearly we both feel they could/should have done better, despite the circumstances they found themselves in.
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Old 2nd Mar 2008, 19:32
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Agree with above. No need to get emotional about the crew part of Kegworth. They were just one part of the causal factors in a lineup of the cheese. Remove any layer and it would only be an incident.

Multiple recommendations followed and the accident was a learning point for the aviation community to adopt.

If there is no blame than there will be less defensiveness and much more likey for all to learn from this combination.
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Old 2nd Mar 2008, 20:04
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There's some very dubious analysis in the report on Kegworth.

However, there are several recommendations about training and displays.

I believe it's in this latter respect that the report got it right, and I don't believe that

Their incorrect diagnosis of the problem must, therefore, be attributed to their too rapid reaction...

is substantiated.

Yes, people make mistakes, and designers and airworthiness authorities should allow for those mistakes in their machinations. That's how aviation safety works in the human-controlled environment, and accidents such as Kegworth (and Grammatikos) point to inadequacies in design and training, not in the human being.

http://www.amazon.com/Human-Error-Si.../dp/1899287728
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Old 2nd Mar 2008, 23:56
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I'm sorry but the way I read it, moggiee WAS, as you put it, "slagging the crew off".

And in this case, yes, we can be constructive with our criticism (ok, we missed several clues, so how can we do better?) or destructive (you're stupid, you missed the clues)

As always on these forums it's nigh on impossible to judge the timbre of a post. And I'm sure that moggiee would agree that his post could easily be construed as being negative, rather than an attempt to adress the problem in a constructive manner.

I'm sure we all learned important lessons from coverage and research into the Kegworth accident, but can anyone honestly say that in that situation, with the indications that occurred, they would have made different decisions?

I'd like to hope that I would, with the benefit of having studied that accident, but who really knows?
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Old 3rd Mar 2008, 00:31
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Originally Posted by matt_hooks
With all due respect moggiee, we can ALL have 20/20 (sorry, 6/6) hindsight, but you weren't there on the flightdeck dealing with the emergency.

I'm sure anyone who knows anything about flying knows about Kegworth, and yes, there WERE clues, but the crew were dealing with the situation in a pressured environment and missed them.

They're human, humans make mistakes sometimes!

The design of the cockpit instrumentation iirc was found to have contributed to the accident also.

It was one of those tragic cases where all the holes lined up. For sure we should look at it, and try to learn lessons from it, but to sit there and judge the actions of the flight crew is non-productive and downright disrespectful!

</rant>
To address your points:

I HAVE been there - one night I had a tyre explode in a wheel well, causing a double engine failure (4 jet airliner), loss of 50% of our fuel, failure of the LH hydraulics and structural damage to the fuselage etc. - a MORE pressurised and complex situation than the BMA crew had to deal with. We got it right because we took our time and got the diagnosis right first time.

The Kegworth environment was doubly pressurised because the Captain took control from the FO (changing crew roles at a critical time) and disconnected the autopilot - dramatically increasing his own workload. This meant that he was so overloaded that, by his own admission, he was unable to determine the nature of the failure - thus leaving the diagnosis to the FO. Sadly, the FO was wrong but the Captain had turned the two crew aeroplane into a single crew one and removed the cross-check that is the cornerstone of multi-crew procedures.

The cockpit instrumentation was poorly designed - but there were at least 4 separate indications of engine problems on the LH motor, surely enough for most people? Enough, at least, if you actually take the time to look at them.

In addition to the above, the Captain did not make full use of the cabin crew - in fact he actively discourage the cabin crew from passing the vital info (I know one of the stewardesses on that flight, that piece of info came first hand!). Again, from personal experience I have found that on at least two occasions, one of my cabin crew has given me the final piece of info required to complete an accurate diagnosis.

As for disgracefully slagging off the crew - apart from the input from the stewardess, ALL of the above was said by the AAIB.

Yes the "holes lined up" - but speaking from PERSONAL experience, I know that it is my job to act as safety net when they do so. Not every situation conforms to a nice, neat scenario as practised in the simulator, but that's why pilots and cabin crew are there - to use their experience, knowledge and training to read between the lines and improvise if required.
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Old 3rd Mar 2008, 07:03
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It is amazing that the crew had had zero simulator time on this aircraft type.
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Old 3rd Mar 2008, 10:57
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BMA accident at Kegworth

As my "Pen Name" suggests I am one of the older brigade, however I was involved in multi-engined operations for many years as a Flight Engineer on a variety of aircraft culminating on the B747.

My recollection of reports around the time of the Kegworth accident indicated the crew held a false notion that bleed air from only the No 2 engine was used in the operation of the air conditioning system, a notion which was planted in their minds by incorrect information from a ground instructor during conversion to type. When smoke was apparent, as a result of damage to the No 1 engine, the crew believed the Vibration indications "must" have been relative to the No 2 engine and in haste closed that engine down and at the same time commenced an emergency descent. The fact that the wrong engine had been shut down did not become apparent until the crew endeavoured to spool up the damaged operating engine, all too late in the approach to restart the No 2 engine. This was not the first time, nor will it be the last, that to have "hastened slowly" would have resulted in a better outcome.
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Old 3rd Mar 2008, 12:22
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Originally Posted by twistedenginestarter
It is amazing that the crew had had zero simulator time on this aircraft type.
Indeed, although they had done a 737-300 type rating (same engines, different instruments).

It's fair to say that BMA (as they were then) badly let down the crew with a second rate training programme - a failing in which the CAA played a part by approving the course.

With regard to the smoke issue - on previous types that the captain had flown, the aircraft fed cabin air from the right hand engine and flight deck from the left. On the 737-400 the two bleed sources are mixed so can no longer be used to determine the source of the smoke and location of the failure.

I have had smoke problems on an aircraft due to a failed compressor and it was very hard to locate the source of the smoke (I saw the smoke in the cabin before I saw the smoke around my knees!) - but engine instrumentation is generally unequivocal.

The reports can be downloaded from the AAIB website and make interesting reading. When used as a case study on MCC/CRM training (and referring to their existing understanding of the chain of events), most students initially feel that the accident was beyond the control of the crew. After evaluating the data in the report, they always (in my experience) come round to the view that the crew rushed the decision making and diversion, mismanaged their own workshare and workload and failed to make full use of their available resources (cabin crew etc.).

This isn't "slagging them off", it's a matter of record and nothing more.

AAIB weblink for reports on this accident:

http://www.aaib.gov.uk/publications/..._90_502831.cfm
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Old 5th Mar 2008, 18:01
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When used as a case study on MCC/CRM training (and referring to their existing understanding of the chain of events), most students initially feel that the accident was beyond the control of the crew. After evaluating the data in the report, they always (in my experience) come round to the view that the crew rushed the decision making and diversion, mismanaged their own workshare and workload and failed to make full use of their available resources (cabin crew etc.).
And I suppose that the students in your MCC/CRM training are magically exempt the environmental capture involved in being on the course, and thus don't come round to the conclusion that the crew did not perform well because they know it's what's expected of them in their environment...

Could you demonstrate to us precisely what benefit the industry has derived from CRM and MCC, please?

No? Thought not. No-one can, because it hasn't.
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Old 5th Mar 2008, 18:33
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Zorst
You must be one of those perfect pilots who is too good to gain anything from CRM.
MCC is a licence requirement and for pilots that have never been in a "crew" is a big help to to settling down in the airline environment.
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Old 5th Mar 2008, 18:57
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Not at all, I'm just making the point that no study has ever identified a tangible benefit from all this 'training'.

I've seen some pretty shoddy MCC training, too.
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Old 5th Mar 2008, 19:30
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It is amazing that the crew had had zero simulator time on this aircraft type.
They had infact had exactly the same sim time as any other pilots worldwide on this type as there were precisely zero 737-400 simulators in the world at the time!

It would be impossible to restart the engine if the fire warning handle had been pulled (i think) because the engine bleed sov, fuel sov would have been forced closed.
Wrong. You can push the fire handle back in & it is all restored.
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Old 5th Mar 2008, 21:37
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Moggie et al. I happen to agree that the crew, in this instance, took a hasty decision, acting on what turned out to be false information.

And I was always taught that the FIRST thing you do in any emergency situation is sit on your hands, take the time to seek out and assimilate all information before making decisions or acting.

As for the value of MCC training, I think it's one of the great imponderables. It's very difficult to prove a negative (such as that MCC training has no positive effect on safety) but if done properly I can't see how such exposure to the multi crew environment can be harmful.

And Moggiee, I respect that you have direct personal experience of an emergency situation, and that it was handled in a professional manner with a succesful (i.e. safe) outcome. But can you honestly say that you would not be prone to making exactly the same mistakes as the crew at Kegworth did, given the information that they had, and the incorrect technical detail that they had been given? Yes I agree, a more methodical approach might well have led them to identify the problem correctly and avert the tragic outcome, but to second guess their actions is not very productive. To look at them, and learn from them, that is productive, but merely to point the finger of blame less so (I hasten to add that's just my opinion)
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Old 5th Mar 2008, 22:26
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Originally Posted by matt_hooks
And Moggiee.......can you honestly say that you would not be prone to making exactly the same mistakes as the crew at Kegworth did, given the information that they had, and the incorrect technical detail that they had been given?
Yes I firmly believe that I can - because I was trained to:

1) Not change the roles of the pilots (PF/PNF) in the middle of an emergency,

2) to use engine instrumentation to identify which engine has failed/partially failed rather than intangibles such as smoke and noise and

3) make full use of my cabin crew as eyes and ears down the back.

By recognising the fact that the crew rushed a decision and did NOT make full use of the instrumentation which (for all its design faults) was showing FOUR separate abnormal indications for a problem on the left engine, we can learn that the methodical approach to diagnosis brings a greater chance of a correct diagnosis. This is not pointing the finger of blame so much as identifying causes for the accident.

By the way, as well as the previously mentioned incident I have had 3 other engine failures, one RTO, smoke in the cabin/flightdeck, hydraulic failures, gear problems etc. None of these were mis-identified because we took our time and used the available information to identify the problems. The Kegworth crew used one piece of erroneous information (airconditioning design) in place of FOUR engine indications to identify which engine was giving trouble.

Engine problems should be identified by using engine instruments as a start point, not last resort. It's not that difficult a concept to take on board, I don't think. You only get one chance to "get it right first time".

For the previous posters:

The crew did the "Engine failure and shutdown" checklist because there was no "Fire" and at that time the QRH did not contain a "High Vibration" checklist.

ZORST Re: MCC - yes there ARE tangible benefits. Airlines that I have dealt with have reported lower training costs on type ratings with WELL TRAINED MCC graduates than they experienced before MCC came along. There are bad MCC courses and good MCC courses - just as there are good and bad examples of ALL courses.

Several of my colleagues from the FTO at which I work have moved on from PPL instructing to joining large airlines and feedback from them says that they felt that the MCC course they did gave them a biog leg up (not least because they were already familiar with an SOP that had 95%+ commonality with the one at the airline they joined).

When I did my first multi-crew TR I had no CRM or MCC training - and found that whilst the transition to a 4 jet airliner was a piece of cake on the flying front, the multi-crew relationship was a different kettle of fish. Having seen MCC graduates at work, I can see the benefits.

Still, that's digressing from the point of the thread.

Last edited by moggiee; 5th Mar 2008 at 22:39.
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