Vliegtuigongeval op 08 JAN 1989 met Boeing 737-4Y0 G-OBME

Home » Database » 1989

Status:	Accident investigation report completed and information captured
Datum:	zondag 8 januari 1989
Tijd:	20:25
Type:	Boeing 737-4Y0
Luchtvaartmaatschappij:	British Midland Airways - BMA
Registratie:	G-OBME
Constructienummer:	23867/1603
Bouwjaar:	1988-10-06 (3 months)
Aantal vlieguren:	521
Motoren:	2 CFMI CFM56-3C1
Bemanning:	slachtoffers: 0 / inzittenden: 8
Passagiers:	slachtoffers: 47 / inzittenden: 118
Totaal:	slachtoffers: 47 / inzittenden: 126
Schade:	Vernield
Gevolgen:	Written off (damaged beyond repair)
Plaats:	nabij Kegworth ( Verenigd Koninkrijk)
Fase:	Nadering (APR)
Soort vlucht:	Binnenlandse lijnvlucht
Vliegveld van vertrek:	London-Heathrow Airport (LHR/EGLL), Verenigd Koninkrijk
Vliegveld van aankomst:	Belfast International Airport (BFS/EGAA), Verenigd Koninkrijk
Vluchtnummer:	BD092

Beschrijving:
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:

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:

Investigating agency:	AAIB
Status:	Investigation completed
Duration:	1 year and 8 months
Accident number:	AAIB AAR 4/1990
Download report:	Final report

Bronnen:

» SKYbrary
» ICAO Adrep Summary 3/91 (#9)
» ICAO Circular 262-AN/156 (1-75)

Veiligheidsmaatregelen

AAIB issued 31 Safety Recommendations

Issued: 11-JAN-1989	To: CAA	(G-OBME-1)
That the CAA consider increasing the frequency of existing engine inspections and engine health monitoring on Boeing 737-300 and Boeing 737-400 aircraft until the causes of the engine failure(s) are established.
Issued: 11-JAN-1989	To: CAA	(G-OBME-2)
That the CAA call for an examination of the Boeing 737-300 and Boeing 737-400 engine Fire/Overheat and Vibration monitoring circuitry for left/right engine sense.
Issued: 10-FEB-1989	To: CAA	(G-OBME-3)
The Civil Aviation Authority, in conjunction with the engine manufacturer, consider instituting inspection procedures for the examination of the fan stage of CFM56 engines to ensure the early detection of damage that could lead to the failure of a blade.
Issued: 10-FEB-1989	To: CAA	(G-OBME-4)
The Civil Aviation Authority review the advice given in the Boeing 737-400 Maintenance Manual concerning the excessive generation of heat during blending operations with power grinding and blending tools.
Issued: 23-FEB-1989	To: CAA	(G-OBME-10)
The CAA should request the Boeing Commercial Airplane Company to produce amendments to the existing aircraft Flight Manuals to indicate what actions should be taken when engine-induced high vibration occurs, accompanied by smoke and/or the smell of burning entering the flight deck and/or cabin.
Issued: 23-FEB-1989	To: CAA	(G-OBME-5)
The CAA should take action to advise pilots of Boeing 737-300/400 aircraft, and of other types with engines which have similar characteristics, that where instances of engine-induced high vibration occur, they may be accompanied by associated smoke and for smells of burning entering the flight deck and/or cabin through the airconditioning system, due merely to blade tip contact between fan/compressor rotating assemblies and the associated abradable seals.
Issued: 23-FEB-1989	To: CAA	(G-OBME-6)
The CAA should review the current attitude of pilots to the engine vibration indicators on Boeing 737-300/400 aircraft, and other applicable types with turbofan engines, with a view towards providing flight crews with an indication of the pertinence of such vibration instruments when engine malfunctions or failures occur.
Issued: 30-MAR-1990	To: CAA	(G-OBME-11)
The CAA should ensure that flight crew currency training in simulators includes practice reprogramming of flight management systems, or any other such systems which control key approach and landing display format, during unplanned diversions so that they remain practised in the expeditious use of such systems.
Issued: 30-MAR-1990	To: CAA	(G-OBME-12)
The CAA should review the current guidance to air traffic controllers on the subject of offering a discrete RT frequency to the commander of a public transport aircraft in an emergency situation, with a view towards the merits of positively offering this important option.
Issued: 30-MAR-1990	To: CAA	(G-OBME-13)
The CAA should review current airline transport pilot training requirements to ensure that pilots, who lack experience of electronic flight displays, are provided with familiarisation of such displays in a flight simulator, before flying public transport aircraft that are so equipped.
Issued: 30-MAR-1990	To: CAA	(G-OBME-14)
Training exercises for pilots and cabin crew should be introduced to improve coordination between technical and cabin crews in response to an emergency.
Issued: 30-MAR-1990	To: CAA	(G-OBME-15)
The CAA should review current airline transport pilot training requirements with a view towards considering the need to restore the balance in flight crew technical appreciation of aircraft systems, including systems response under abnormal conditions, and to evaluate the potential of additional simulator training in flight deck decision making.
Issued: 30-MAR-1990	To: CAA	(G-OBME-16)
The type certification requirements for gas turbine engines should be amended so that it is mandatory to perform instrumented flight tests to demonstrate freedom from damaging vibratory stresses at all altitude conditions and powers which an engine will encounter in service
Issued: 30-MAR-1990	To: CAA	(G-OBME-17)
The potential for fuel and oil system leakage within the fan case area of high by-pass turbofan engines, during conditions of excessive vibration, should be reviewed by the engine manufacturers and the CAA with a view towards modifying such systems to minimise such leakage, and the associated fire risk
Issued: 30-MAR-1990	To: CAA	(G-OBME-18)
The CAA should review the existing Joint Airworthiness Requirements concerning fuel tank protection from the effects of main landing gear and engine detachment during ground impact and include specific design requirements to protect the fuel tank integrity of those designs of aircraft with wing-mounted engines
Issued: 30-MAR-1990	To: CAA	(G-OBME-19)
The CAA should expedite current research into methods of providing flight deck crews of public transport aircraft with visual information on the status of their aircraft by means of external and internal closed circuit television monitoring and the recording/recall of such monitoring, including that associated with flight deck presentations, with a view towards producing a requirement for all UK public transport aircraft to be so equipped
Issued: 30-MAR-1990	To:	(G-OBME-20)
The manufacturers of existing flight data recorders which use buffering techniques should give consideration to making the buffers non-volatile and hence recoverable after loss of power, and EUROCAE and the CAA should reconsider the concept of allowing volatile memory buffering in flight data recorders
Issued: 30-MAR-1990	To: CAA	(G-OBME-21)
Where engine vibration is an available parameter for flight data recording, the CAA should consider making a requirement for it to be recorded at a sampling rate of once every second
Issued: 30-MAR-1990	To: CAA	(G-OBME-22)
The CAA should actively seek further improvement in the standards of JAR 25.561/.562 and the level of such standards should not be constrained by the current FAA requirements
Issued: 30-MAR-1990	To: CAA	(G-OBME-23)
The CAA should require that, for aircraft passenger seats, the current loading and dynamic testing requirements of JAR 25.561 and .562 be applied to newly manufactured aircraft coming onto the UK register and, with the minimum of delay, to aircraft already on the UK register
Issued: 30-MAR-1990	To: CAA	(G-OBME-24)
In addition to the dynamic test requirements, the CAA should seek to modify the JARs associated with detailed seat design to ensure that such seats are safety-engineered to minimise occupant injury in an impact
Issued: 30-MAR-1990	To: CAA	(G-OBME-25)
The CAA should initiate and expedite a structured programme of research, in conjunction with the European airworthiness authorities, into passenger seat design, with particular emphasis on: (i) Effective upper torso restraint. (ii) Aft-facing passenger seats.
Issued: 30-MAR-1990	To: CAA	(G-OBME-26)
The certification requirements for cabin floors of new aircraft types should be modified to require that dynamic impulse and distortion be taken into account and these criteria should be applied to future production of existing designs
Issued: 30-MAR-1990	To: CAA	(G-OBME-27)
The CAA should initiate research, in conjunction with the European airworthiness authorities, into the feasibility of a significant increase in cabin floor toughness beyond the level of the current J AR/F AR seat requirements
Issued: 30-MAR-1990	To: CAA	(G-OBME-28)
The CAA implement a programme to require that all infants and young children, who would not be safely restrained by supplementary or standard lap belts, be placed in child-seats for take-off, landing and flight in turbulence
Issued: 30-MAR-1990	To: CAA	(G-OBME-29)
The CAA expedite the publication of a specification for child seat designs
Issued: 30-MAR-1990	To: CAA	(G-OBME-30)
The certification requirements for cabin stowage bins, and other cabin items of mass, should be modified to ensure the retention of these items to fuselage structure when subjected to dynamic crash pulses substantially beyond the static load factors currently required
Issued: 30-MAR-1990	To: CAA	(G-OBME-31)
The CAA consider improving the airworthiness requirements for public transport aircraft to require some form of improved latching to be fitted to overhead stowage bins and this should also apply to new stowage bins fitted to existing aircraft.
Issued: 30-MAR-1990	To: CAA	(G-OBME-7)
The CAA should require that pilot training associated with aircraft which are equipped with modern vibration systems16, and particularly those aircraft which are fitted with high by-pass turbofan engines, should include specific instruction on the potential value of engine vibration indicators in assisting the identification of an engine which has suffered a failure associated with its rotating assemblies.
Issued: 30-MAR-1990	To: CAA	(G-OBME-8)
The regulatory requirements concerning the certification of new instrument presentations should be amended to include a standardized method of assessing the effectiveness of such displays in transmitting the associated information to flight crew, under normal and abnormal parameter conditions. In addition, line pilots should be used in such evaluations.
Issued: 30-MAR-1990	To: CAA	(G-OBME-9)
The CAA should require that the engine instrument system on the Boeing 737-400, and other applicable public transport aircraft, be modified to include an attention-getting facility to draw attention to each vibration indicator when it indicates maximum vibration.

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Foto's

accident date: 08-01-1989
type: Boeing 737-4Y0
registration: G-OBME

Final flight path

Seat map Boeing 737-4Y0 G-OBME

accident date: 08-01-1989
type: Boeing 737-4Y0
registration: G-OBME

Kaart

Deze kaart geeft het vliegveld van vetrek weer en de geplande bestemming van de vlucht. De lijn tussen de vliegvelden geeft niet de exacte vliegroute weer.
De afstand tussen London-Heathrow Airport en Belfast International Airport bedraagt 518 km (324 miles).
Accident location: Exact; deduced from official accident report.

This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.

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Boeing 737-400

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