Accident Boeing 737-4Y0 G-OBME,

ASN Wikibase Occurrence # 326396

Date:	Sunday 8 January 1989
Time:	20:25
Type:	Boeing 737-4Y0
Owner/operator:	British Midland Airways - BMA
Registration:	G-OBME
MSN:	23867/1603
Year of manufacture:	1988
Total airframe hrs:	521 hours
Engine model:	CFMI CFM56-3C1
Fatalities:	Fatalities: 47 / Occupants: 126
Aircraft damage:	Destroyed, written off
Category:	Accident
Location:	near Kegworth - United Kingdom
Phase:	Approach
Nature:	Passenger - Scheduled
Departure airport:	London-Heathrow Airport (LHR/EGLL)
Destination airport:	Belfast International Airport (BFS/EGAA)
Investigating agency:	AAIB
Confidence Rating:	Accident investigation report completed and information captured

Narrative:
British Midland Airways Flight 092 took off from London-Heathrow Airport at 19:52 for a flight to Belfast, Northern Ireland. Some 13 minutes later, while climbing through FL283, moderate to severe vibration was felt, accompanied by a smell of fire in the cockpit. The outer panel of one of the no. 1 engine fan blades detached, causing compressor stalls and airframe shuddering. Believing the No. 2 engine had been damaged the crew throttled it back. The shuddering stopped and the No 2 engine was shut down. The crew then decided to divert to East Midlands Airport. The flight was cleared for an approach to runway 27. At 900 feet, 2.4nm from the runway threshold, the no. 1 engine power suddenly suffered a decrease in power. As the speed fell below 125 knots, the stick shaker activated and the aircraft struck trees at a speed of 115 knots. The aircraft continued and impacted the western carriageway of the M1 motorway 10 m lower and came to rest against a wooded embankment, 900 m short of the runway.

PROBABLE CAUSE: "The operating crew shut down the No 2 engine after a fan blade had fractured in the No 1 engine. This engine subsequently suffered a major thrust loss due to secondary fan damage after power had been increased during the final approach to land. The following factors contributed to the incorrect response of the flight crew: 1. The combination of heavy engine vibration, noise, shuddering and an associated smell of fire were outside their training and experience; 2. They reacted to the initial engine problem prematurely and in a way that was contrary to their training; 3. They did not assimilate the indications on the engine instrument display before they throttled back the No. 2 engine; 4. As the No 2 engine was throttled back, the noise and shuddering associated with the surging of the No 1 engine ceased, persuading them that they had correctly identified the defective engine; 5. They were not informed of the flames which had emanated from the No.1 engine and which had been observed by many on board, including 3 cabin attendants in the aft cabin."

Accident investigation: