Kegworth air disaster
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 The scene of the disaster, with the runway that G-OBME failed to reach at the top of the picture |
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| Summary | |
|---|---|
| Date | January 8, 1989 |
| Type | Engine failure, Pilot error |
| Site | Kegworth, Leicestershire, UK |
| Fatalities | 47 |
| Injuries | 79 |
| Aircraft | |
| Aircraft type | Boeing 737-400 |
| Operator | British Midland |
| Tail number | G-OBME |
| Passengers | 118 |
| Crew | 8 |
| Survivors | 79 |
The Kegworth Air Disaster occurred on January 8, 1989, when British Midland Flight 092, a Boeing 737-400, crashed onto the embankment of the M1 motorway near Kegworth, Leicestershire, UK. The aircraft was preparing to land at the East Midlands Airport. 47 people were killed and 74 were seriously injured, including seven members of the flight crew.
Contents |
[edit] History
The aircraft was a British Midland 737-400, tail number G-OBME, on a scheduled flight from London Heathrow Airport to Belfast, Northern Ireland, having already flown from Heathrow to Belfast and back that day. After taking off from Heathrow at 7:52pm, Flight 92 was climbing through 28,300 feet to reach its cruising altitude of 35,000 feet when one of the fan blades on the left engine suddenly ruptured. While the pilots did not know the source of the problem, a pounding noise was suddenly heard, accompanied by severe vibrations. In addition, smoke poured into the cabin through the ventilation system and an aroma of burning entered the plane. Several passengers sitting near the rear of the plane noticed smoke and sparks coming from the left engine.
The flight was diverted to the East Midlands Airport, which was only a few minutes' flight away and reachable with only one engine.
After the initial blade fracture, the captain, Kevin Hunt, had disengaged the plane's autopilot. When Hunt asked the First Officer, David McClellan, which engine was malfunctioning, McClellan replied: 'It's the le... it's the right one'. In previous versions of the 737, the air conditioning ran through the right hand engine, but on the 737-400 it ran through both. The pilots had been used to the older version of the aircraft and did not realize that this aircraft (which had only been flown by British Midland for 520 hours over a two-month period) was different. When they smelled the smoke they assumed it was coming from the right engine; this led them to shut down the working right engine instead of the malfunctioning left engine. (They had no way of visually checking the engines from the cockpit, and the cabin crew did not inform them that smoke and flames had been seen from the left engine.)
When the pilots shut down the right engine, they could no longer smell the smoke, which led them to believe that they had correctly dealt with the problem. As it turned out, this was simply a coincidence. When the autothrottle was disengaged to shut down the right engine, the fuel flow to the left engine was reduced and the excess fuel which had been igniting in the jet exhaust disappeared; therefore, the ongoing damage was reduced, the smoke smell ceased, and the vibration reduced, although it would still have been visible on cockpit instruments.
During the final approach to the East Midlands Airport, more fuel was pumped into the damaged engine to maintain speed, which caused it to cease operating entirely and burst into flames. The captain attempted to restart the right engine by windmilling, using the air flowing through the engine to rotate the turbine blades and start the engine, but the aircraft was by now flying too slowly for this. The captain managed to keep the now-gliding aircraft airborne long enough to avoid a crash landing in the village of Kegworth by pointing the nose up and stretching the glide, but just before crossing the M1 motorway, the tail hit the ground and the aircraft bounced back into the air and over the motorway, crashing on the opposite embankment and breaking up into three sections.
[edit] Casualties
Forty-seven of the 118 passengers (126 people on board including flight staff) died (39 at the scene, 8 later). All eight of the flight crew survived the accident. Of the 79 survivors, 5 had minor injuries and 74 were seriously injured. No one on the motorway was hurt (and no vehicles were damaged), although one driver who was the first person to help at the scene did subsequently receive damages for post-traumatic stress disorder.
[edit] Causes
[edit] Engine malfunction
Analysis of the engine from the crash determined that the fan blades (LP Stage 1 compressor) of the uprated CFM56 engine used on the 737-400 were subject to abnormal amounts of vibration when operating at high power settings above 25,000 ft. As it was an upgrade to an existing engine, in-flight testing was not mandatory, and the engine had only ever been tested in the laboratory. Upon this discovery all 737-400s (around 100 at the time) were grounded and the engines modified. Following the crash, it is now mandatory to test all newly designed and signficiantly redesigned turbofan engines under representative flight conditions.
This unnoticed vibration created excessive metal fatigue in the fan blades, and on G-OBME this caused one of the fan blades to break off. This damaged the engine terminally and also upset its delicate balance, causing a reduction in power and an increase in vibration. The autothrottle attempted to compensate for this by increasing the fuel flow to the engine, however the damaged engine was unable to burn all the additional fuel, with much of it igniting in the exhaust flow, thus creating a large trail of flame behind the engine.
[edit] Shutting down the wrong engine
The captain (Kevin Hunt) believed the right engine was malfunctioning due to the smell of smoke, because in previous Boeing 737 variants, bleed air for the air conditioning system was taken from the right engine. However, starting with the Boeing 737-400 variant, Boeing redesigned the system to use bleed air from both engines. Several cabin staff and passengers also noticed that the left engine had a stream of unburnt fuel igniting in the jet exhaust, but this information was not passed-on to the flight crew, because they thought that the pilots knew what they were doing.
Besides the unfortunate coincidence of the smoke disappearing when the autothrottle was disengaged to shut down the right engine, the pilots may have gotten into the habit of disregarding the readings of vibration warning meters—early ones were unreliable but the flying crew of G-OBME do not seem to have been aware that newer ones were more reliable. The dials were also smaller than on the previous versions of the 737 in which they had the majority of their experience. The pilots had received no simulator training on the new model, as no simulator for the 737-400 existed in the UK at that time.
[edit] Aftermath
Evaluation of the injuries sustained led to considerable improvements in aircraft safety and emergency instructions for passengers. The official report into the disaster made 31 safety recommendations.
There is a memorial to "those who died, those who were injured and those who took part in the rescue operation", in the village cemetery in nearby Kegworth, together with a garden made using soil from the crash site.
Captain Hunt and First Officer McClelland were seriously injured in the crash, and were later dismissed following the criticisms of their actions in the AAIB report.
[edit] Trivia
- The National Geographic Channel documentary series Seconds From Disaster dedicated the third episode of its second season to the disaster.
- In the book SAS The Soldiers Story an SAS trooper named Johnny Two-Combs describes how, on the way to a training course, he and his troop were traveling along the M1 when the air crash happened. The unit offered to help and in the news footage of the wrecked aircraft, a member of the team can be seen rappelling down from the tail of the plane. The Army truck is also visible in some photos.
[edit] See also
[edit] References
- Macarthur Job, Air Disaster Volume 2: Aerospace Publications Pty Ltd, 1996, ISBN 1-875671-19-6, p. 173-185
- David Owen, Air Accident Investigation: Patrick Stephens Limited, 2001, ISBN 0-7509-4495-1. (The Kegworth air disaster is given a detailed mention in Chapter 9, "Pressing the Wrong Button")
- Jack Ramsay, SAS, The Soldiers Story: Pan Books, 1997, ISBN 0-330-34750-0.
