Kegworth air disaster
52°49′55″N 1°17′57.5″W / 52.83194°N 1.299306°W / 52.83194; -1.299306
The Kegworth air disaster occurred when British Midland Airways Flight 092, a Boeing 737-400, crashed onto the motorway embankment between the M1 motorway and A453 road near Kegworth, Leicestershire, England, while attempting to make an emergency landing at East Midlands Airport on 8 January 1989.[1]
The aircraft was on a scheduled flight from London Heathrow Airport to Belfast International Airport when a fan blade broke in the left engine, smoke was drawn into the cabin through the air conditioning system. The pilots believed this indicated a fault in the right engine, since earlier models of the 737 ventilated the cabin from the right, and they were unaware that the 737-400 used a different system. The pilots retarded the right thrust lever and the symptoms of smoke and vibration cleared, leading them to believe the problem had been identified and then the right engine was shut down. On the final stage of the approach thrust was increased on the left engine and the tip of the fan blade that had lodged in the cowling from the earlier event became dislodged and was drawn into the core of the engine, damaging it and causing a fire. Of the 126 plus 1 people aboard, 47 died and 74 sustained serious injuries. The fan blade had initially suffered a fracture caused by aerodynamic flutter. Those responsible for the pre-certification test programme and the issue of a Certificate of Airworthiness 'acted contrary' to the wealth of literature that was available on this subject. This knowledge made clear that static ground testing to discover the presence of flutter was unreliable and the fan blade had to be subjected to the full flight envelope to be certain of the test results.
The accident was the first hull loss of a Boeing 737 Classic aircraft,[2] and the first fatal accident involving a Boeing 737 Classic aircraft.[3]
Aircraft involved and crew
Aircraft
The aircraft was a British Midland-operated Boeing 737-4Y0,[a] registration G-OBME,[4] on a scheduled flight from London Heathrow Airport to Belfast International Airport, Northern Ireland, having already flown from Heathrow to Belfast and back that day. The 737-400 was the newest design from Boeing, with the first unit entering service less than four months earlier, in September 1988. G-OBME itself had been in service for 85 days, since 15 October 1988, and had accumulated 521 airframe hours. The aircraft was powered by two CFM International CFM56 turbofan engines.[5][6][7]
Cockpit crew
The flight was crewed by 43-year-old Captain Kevin Hunt and 39-year-old First Officer David McClelland. Hunt had been with British Midland since 1966 and had about 13,200 hours of flying experience. First Officer McClelland joined the airline in 1988 and had about 3,300 total flight hours. Between them, the pilots had close to 1,000 hours in the Boeing 737 cockpit (Hunt had 763 hours, and McClelland had 192 hours), but only 76 of these had been in Boeing 737-400 series aircraft (Hunt 23 hours and McClelland 53 hours).[8]
Accident
After taking off from Heathrow at 19:52,[b] Flight BD 092 was climbing through 28,300 feet (8,600 m) to reach its cruising altitude of 35,000 feet (11,000 m) when a blade detached from the fan of the port (left) engine. The pilots did not know the source of the problem, but heard a pounding noise, accompanied by severe vibrations. Smoke poured into the cabin through the ventilation system, and passengers became aware of the smell of burning.[9] Several passengers sitting near the rear of the plane noticed smoke and sparks coming from the left engine.[10] The flight was diverted to nearby East Midlands Airport[11] at the suggestion of British Midland Airways Operations.[12]
After the initial blade fracture, Captain Kevin Hunt, the non-handling pilot, took control without first advising McClelland, and disengaged the plane's autopilot.[13] Hunt then asked First Officer David McClelland which engine was malfunctioning, McClelland replied: "It's the le.... It's the right one".[13] In previous versions of the 737, the right (number 2) engine supplied air to the flight deck. The pilots had been used to the older version of the aircraft and did not realise that this aircraft was different. The captain later claimed that his perception of smoke as coming forward from the passenger cabin led them to assume the fault was in the right engine.[14] The pilots throttled back the working right engine instead of the malfunctioning left engine.[14] They had no way of visually checking the engines from the cockpit, and the cabin crew – who did not hear the captain refer to the right hand engine in his cabin address – did not inform them that smoke and flames had been seen from the left engine.[15]
When the pilots retarded the right engine, they could no longer smell the smoke or feel the vibration, which led them to believe that they had correctly dealt with the problem. As it turned out, this was due to a combination of the Power Management Control unit and autothrottle which was disengaged prior to shutting down the right engine, the fuel flow to both engines was reduced, and the excess fuel, which had been igniting in the left engine exhaust, disappeared; therefore, the ongoing damage was reduced, the smell of smoke ceased, and the vibration reduced, although it would still have been visible on cockpit instruments which were at 'best unclear and at worst misleading' according to Dr Roger Green from the RAF Institute of Air Medicine.[16]
During the final approach to the East Midlands Airport, the pilots selected increased thrust from the operating, damaged engine. This led to an engine fire, caused by the tip of the fan blade dislodging from the cowling, going into the core of the engine and ceasing to operating entirely. The ground proximity warning system activated, sounding several "glideslope" warnings. The pilots attempted to restart the right engine by windmilling, but the aircraft was by now only 900[clarification needed] above the ground and flying too slowly for a restart. At 20:24:33, Captain Hunt broadcast to the passengers via the aircraft's public-address system: "Prepare for crash landing," instructing passengers to take the brace position. The stick shaker then activated. Just before crossing the M1 motorway at 20:24:43, the tail and main landing gear struck the ground at a speed of 213 km/h (115 kn; 132 mph) and the aircraft bounced back into the air and over the motorway, knocking down trees and a lamp post before crashing on the far embankment around 475 metres (519 yd) short of the active runway's paved surface and about 630 metres (690 yd) from its threshold. The aircraft broke into three sections.[17] This was adjacent to the motorway, but no vehicles were travelling on that part of the M1 at the moment of the crash.[18]
Casualties
Of the 118 passengers on board, 39 were killed outright in the crash and eight died later of their injuries, giving a total of 47 fatalities. All eight crew members survived the accident. Of the 79 survivors, 74 suffered serious injuries and five suffered minor injuries. In addition, five firefighters also suffered minor injuries during the rescue operation.[19] No-one on the motorway was injured, and all vehicles in the vicinity of the disaster were undamaged. The first person to arrive at the scene and render aid was a motorist, Graham Pearson.[20] A former Royal Marine, he helped passengers for over three hours, and subsequently received damages for post-traumatic stress disorder.[20] Aid was also given by a troop of eight SAS soldiers, four of whom were regimentally qualified paramedics. Their truck had been on the motorway when the crash occurred.[21]
Causes
The investigation established that the wiring associated with the fire warning lights was properly connected. Initially there was a concern that the sensors in the engines and the warning lights on the flight deck may have been cross-wired.[22]
Shutting down of wrong engine
Captain Hunt believed the right engine was malfunctioning due to the smell of smoke in the cabin because in previous Boeing 737 variants bleed air for cabin air conditioning was taken from the right engine. Starting with the Boeing 737-400 variant, Boeing had redesigned the system to use bleed air from both engines.[citation needed] Several cabin staff and passengers noticed that the left engine had a stream of unburnt fuel igniting in the jet exhaust, but this information was not passed to the pilots because cabin staff assumed they were aware that the left engine was malfunctioning.[23]
The smell of smoke disappeared when the autothrottle was disengaged and the right engine shut down due to reduction of fuel to the damaged left engine as it reverted to manual throttle.[16] In the event of a malfunction, pilots were trained to check all meters and review all decisions, and Captain Hunt proceeded to do so. Whilst he was conducting the review, however, he was interrupted by a transmission from East Midlands Airport informing him he could descend further to 12,000 feet (3,700 m) in preparation for the diverted landing. He did not resume the review after the transmission ended, and instead commenced descent.[citation needed]
The dials on the two vibration gauges (one for each engine) were smaller than on the previous versions of the 737 in which the pilots had the majority of their experience and the LED needle went around the outside of the dial as opposed to the inside.[24] 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. At the time, vibration indicators were known for being unreliable[25] (and normally ignored by pilots), but unknown to the pilots, this was one of the first aircraft to have a very accurate vibration readout, although it was still permitted to fly with one gauge unserviceable under Boeing's Minimum Equipment List.[10]
Engine malfunction
Analysis of the engine from the crash determined that the fan blades (LP stage 1 compressor) of the uprated CFM International CFM56 engine used on the 737-400 were subject to abnormal amounts of vibration when operating at high power settings above 10,000 feet (3,000 m).[26] As it was an upgrade to an existing engine, in-flight testing was not mandatory, and the engine had only been tested in the laboratory. Upon this discovery, the remaining 99 Boeing 737-400s then in service were grounded and the engines modified. Following the crash, testing all newly designed and significantly redesigned turbofan engines under representative flight conditions is now mandatory.
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. The damaged engine was unable to burn all the additional fuel, with much of it igniting in the exhaust flow, creating a large trail of flame behind the engine.
Aftermath
The official report into the disaster made 31 safety recommendations.[27] Evaluation of the injuries sustained led to considerable improvements in aircraft safety and emergency instructions for passengers.[10] These were derived from a research programme funded by the CAA and carried out by teams from the University of Nottingham and Hawtal Whiting Structures (an engineering consultancy company). The study between medical staff and engineers used analytical "occupant kinematics" techniques to assess the effectiveness of the brace position.[28] A new notice to operators revising the brace position was issued in October 1993.
The research into this accident led to the formation on 21 November 2016 of the International Board for Research into Aircraft Crash Events, which is a joint co-operation between experts in the field for the purpose of producing an internationally agreed-upon, evidence-based set of impact bracing positions for passengers and (eventually) cabin crew members in a variety of seating configurations. These will be submitted to the International Civil Aviation Organization through its Cabin Safety Group.
A memorial was built in the village cemetery in nearby Kegworth to "those who died, those who were injured and those who took part in the rescue operation", together with a garden made using soil from the crash site.[29]
Captain Hunt and First Officer McClelland, both seriously injured in the crash, were dismissed following the criticisms of their actions in the Air Accidents Investigation Branch report.[30] Hunt suffered injuries to his spine and legs in the crash. In April 1991, he told a BBC documentary, "We were the easy option – the cheap option if you wish. We made a mistake – we both made mistakes – but the question we would like answered is why we made those mistakes."[31] BM later paid McClelland an out-of-court settlement for unfair dismissal.[10]
Alan Webb, the chief fire officer at East Midlands Airport, was made an MBE in the 1990 New Year Honours list for the co-ordination of his team in the rescue efforts that followed the crash.[32] Graham Pearson, a passing motorist who assisted Kegworth survivors at the crash site for three hours, sued the airline for post-traumatic stress disorder and was awarded £57,000 in damages in 1998 (equivalent to £101,800 in 2023).[20]
Media
The crash was featured in a 1991 documentary, an episode of the series Taking Liberties named "Fatal Error". ITV aired a documentary in 1999 of the Kegworth crash. Flight 092 was also featured in an episode of Seconds From Disaster called "Motorway Plane Crash".
It was also featured in the 2011 Discovery Channel documentary Aircrash Confidential.[33]
In 2015, the incident was featured in the episode "Choosing Sides" or "M1 Plane Crash" of the documentary television series Mayday, or Air Crash Investigation, as it is known in the UK.[34]
In 2024, the incident was also featured on the "M1 Plane Crash" episode of Terror at 30,000 Feet on Channel 5.[35]
See also
- TransAsia Airways Flight 235, SA Airlink Flight 8911, Transair Flight 810 and Azerbaijan Airlines Flight 56 - other cases of misidentification of a failing engine
- List of accidents and incidents involving commercial aircraft
Notes
- ^ The aircraft was a Boeing 737-400 model; Boeing assigns a unique customer code for each company that buys one of its aircraft, which is applied as a suffix to the model number at the time the aircraft is built. The code "Y0" was assigned to the leasing company Guinness Peat Aviation, from whom British Midland leased the aircraft.
- ^ McClelland was the pilot flying until the engine failure, after which Captain Hunt took control.[8]
References
- References
- ^ Ranter, Harro. "ASN Aircraft accident Boeing 737-4Y0 G-OBME Kegworth". aviation-safety.net. Aviation Safety Network. Retrieved 12 July 2019.
- ^ Ranter, Harro. "Accident list: Boeing 737". aviation-safety.net. Aviation Safety Network. Retrieved 12 September 2021.
- ^ Ranter, Harro. "Accident list: Boeing 737". aviation-safety.net. Aviation Safety Network. Retrieved 12 September 2021.
- ^ "G-INFO Database". Civil Aviation Authority.
- ^ Trimble 1990, p. 11–22.
- ^ "G-OBME British Midland Boeing 737-400". www.planespotters.net. Retrieved 31 March 2020.
- ^ "British Midland Airways G-OBME (Boeing 737 – MSN 23867)". www.airfleets.net. Airfleets aviation. Retrieved 31 March 2020.
- ^ a b Trimble 1990, p. 8–9.
- ^ Trimble 1990, p. 1.
- ^ a b c d Truslove, Ben (8 January 2014). "Kegworth air disaster: Plane crash survivors' stories". BBC News. BBC Online. Archived from the original on 8 January 2014. Retrieved 8 January 2014. – The content about the safety improvements is from the sidebar "The legacy of Kegworth".
- ^ Trimble 1990, p. 103.
- ^ Trimble 1990, p. 4.
- ^ a b Trimble 1990, p. 3.
- ^ a b Trimble 1990, p. 98.
- ^ Trimble 1990, p. 5.
- ^ a b Trimble 1990, p. 99.
- ^ Trimble 1990, p. 7–8.
- ^ "Why did British Midland plane crash on the M1 near Kegworth?". ITV News. ITV. ITV Report. 8 January 2014. Retrieved 13 January 2017.
- ^ Trimble 1990, p. 7.
- ^ a b c "UK, Air crash hero wins damages". BBC News. BBC. 10 February 1998. Retrieved 16 May 2011.
- ^ Ramsey, Jack (1996). SAS: The soldiers story. London: Pan. pp. 59–64. ISBN 0330347500.
- ^ Trimble 1990, p. 125.
- ^ Trimble 1990, p. 106.
- ^ Trimble 1990, p. 69.
- ^ Trimble 1990, p. 69–70.
- ^ Trimble 1990, p. 118–120.
- ^ Trimble 1990, p. 149–152.
- ^ Scientific and Technical Aerospace Reports. NASA, Office of Scientific and Technical Information. 1993. p. 1423.
- ^ "Kegworth Village, Kegworth Air Disaster 1989". www.kegworthvillage.com. Retrieved 16 August 2021.
- ^ Brookes, Andrew (1994). Disaster in the air. Ian Allan. p. 135. ISBN 0-7110-2037-X.
- ^ This is Nottingham (8 January 2009), Kegworth: Sacked pilots claim they were 'scapegoats', Nottinghampost.com, retrieved 8 January 2014
- ^ "No. 519981". The London Gazette (Supplement). 29 December 1989. p. 15.
- ^ "Aircrash Confidential: Lethal Malfunctions Videos at". Yourdiscovery.com. 24 February 2011. Archived from the original on 12 May 2011. Retrieved 16 May 2011.
- ^ Mayday - Air Crash Investigation (S01-S22), retrieved 16 February 2024
- ^ "M1 Plane Crash".
- Bibliography
- 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")
- HW Structures, CAA Paper 90012 Occupant modelling in aircraft crash conditions: Civil Aviation Authority, 1990, ISBN 0-86039-445-X.
- Hawtal Whiting Technology Group, CAA Paper 95004 A study of aircraft passenger brace positions for impact: Civil Aviation Authority, 1995, ISBN 0-86039-620-7
- Trimble, E J (1990), Report No: 4/1990. Report on the accident to Boeing 737-400, G-OBME, near Kegworth, Leicestershire on 8 January 1989, Air Accidents Investigation Branch
- Report file (G-OBME.pdf Archive)
- Appendices (G-OBME Append.pdf Archive)
External links
- BBC 10th anniversary page about the crash
- BBC 'On This Day' page about the crash
- Pre-crash and crash pictures of the aircraft from Airliners.net
- Field, James (8 January 2019). "Op-Ed: Learning From The Kegworth Air Disaster, 30 Years On". Airways International. Archived from the original on 8 January 2019. Retrieved 8 January 2019.
- Accident description at the Aviation Safety Network
- v
- t
- e
1910
- Thomas Harris (May 1824)
- Cecil Shadbolt (July 1892)
- Percy Pilcher (October 1899)
- Charles Rolls (July 1910)
- Cecil Grace (December 1910)
- Brooklands Flanders Monoplane (May 1912)
- Cody Floatplane (August 1913)
- Maxstoke (August 1918)
- Transatlantic flight of Alcock and Brown (June 1919)
- Airship N.S.11 (July 1919)
- Golders Green Handley Page O/400 (December 1920)
- R38-class airship (June 1921)
- Air Union Farman Goliath (August 1923)
- Daimler Airway de Havilland DH.34 (September 1923)
- KLM Fokker F.III disappearance (April 1924)
- Imperial Airways de Havilland DH.34 (December 1924)
- Air Union Blériot 155 (August 1926)
- Air Union Blériot 155 (October 1926)
- KLM Fokker F.VIII (August 1927)
- Imperial Airways Handley Page W.10 (June 1929)
- Luft Hansa Junkers G 24 (November 1929)
- Air Union Farman Goliath (February 1930)
- Meopham air disaster (July 1930)
- London, Scottish & Provincial Airways Airspeed Courier (September 1934)
- Hillman's Airways de Havilland Dragon Rapide (October 1934)
- SABENA Savoia-Marchetti S.73 (December 1935)
- Jersey Air Disaster (July 1936)
- KLM Croydon accident (December 1936)
- Edmonton air crash (September 1938)
- Jersey Airport disaster (November 1938)
- Dunbeath air crash (August 1942)
- Ruislip Wellington accident (October 1942)
- RAF Hudson (May 1943)
- Gibraltar Liberator AL523 (July 1943)
- Moordown air disaster (March 1944)
- Freckleton air disaster (August 1944)
- USAAF Boeing B-17 on North Barrule (April 1945)
- Elvetham air crash (October 1945)
- Broadway Consolidated Liberator (November 1945)
- Railway Air Services Dakota (December 1946)
- BOAC Douglas C-47 (January 1947)
- Croydon Dakota accident (January 1947)
- Heathrow disaster (March 1948)
- Northwood mid-air collision (July 1948)
- KLM Constellation air disaster (October 1948)
- Exhall mid-air collision (February 1949)
- Manchester BEA Douglas DC-3 accident (August 1949)
- Llandow air disaster (March 1950)
- Heathrow BEA Vickers Viking (October 1950)
- Ringway Dakota (March 1951)
- Aer Lingus C-47 accident (January 1952)
- Farnborough Airshow crash (September 1952)
- Little Rissington UFO incident (October 1952)
- Aldbury Valetta accident (January 1954)
- Swissair Convair CV-240 (June 1954)
- Prestwick air disaster (December 1954)
- Hawker Hunter multiple aircraft accident (February 1956)
- RAF Lakenheath nuclear near-disaster (July 1956)
- London Heathrow Avro Vulcan (October 1956)
- Sutton Wick air crash (March 1957)
- British European Airways Flight 411 (March 1957)
- Blackbushe Viking accident (May 1957)
- Nutts Corner BEA Viscount (October 1957
- Aquila Airways Solent (November 1957)
- Winter Hill air disaster (February 1958)
- London Vickers Viking accident (September 1958)
- Syerston Avro Vulcan (September 1958)
- BOAC Bristol Britannia (December 1958)
- Turkish Airlines Gatwick (February 1959)
- Channel Airways Dakota accident (May 1962)
- BAC One-Eleven test crash (October 1963)
- British United Airways Flight 1030X (April 1965)
- Little Baldon air crash (July 1965)
- Skyways Coach-Air Avro 748 (July 1965)
- Cambrian Airways Liverpool (July 1965)
- Pan Am Flight 292 (September 1965)
- British European Airways Flight 706 (October 1965)
- Felthorpe Trident crash (June 1966)
- Holden's Lightning flight (July 1966)
- Stockport air disaster (June 1967)
- Iberia Flight 062 (November 1967)
- Hawker Hunter Tower Bridge incident (April 1968)
- BOAC Flight 712 (April 1968)
- BKS Air Transport Flight C.6845 (July 1968)
- Ariana Afghan Airlines Flight 701 (January 1969)
- 1969 theft of C-130 (May 1969)
- British European Airways Flight 548 (June 1972)
- Court Line Flight 95 (April 1974)
- British Airways bombing attempt (July 1974)
- Norfolk mid-air collision (August 1974)
- Graham Hill plane crash (November 1975)
- British Airtours Boeing 707 crash (March 1977)
- British Army Gazelle downing (February 1978)
- Dan-Air Flight 0034 (July 1979)
- Biggin Hill Invader crash (September 1980)
- Aer Lingus Flight 164 (May 1981)
- Dan-Air Flight 240 (June 1981)
- Bristow Helicopters Westland Wessex crash (August 1981)
- British Army Gazelle friendly fire incident (June 1982)
- British Airways Sikorsky S-61 crash (July 1983)
- Manchester Airport disaster (August 1985)
- Hindawi affair (April 1986)
- British Army Lynx shootdown (June 1988)
- British International Helicopters Sikorsky S-61N crash (July 1988)
- Pan Am Flight 103 (December 1988)
- template
- Kegworth air disaster (January 1989)
- British Army Gazelle shootdown (February 1990)
- Scotland RAF Shackleton crash (April 1990)
- British Airways Flight 5390 (June 1990)
- Llyn Padarn helicopter crash (August 1993)
- British Army Lynx shootdown (March 1994)
- Mull of Kintyre Chinook crash (June 1994)
- Air Algérie Flight 702P (December 1994)
- Bristow Helicopters Flight 56C (January 1995)
- Royal Air Force Nimrod R1 ditching (May 1995)
- Knight Air Flight 816 (May 1995)
- Virgin Atlantic Flight 024 (November 1997)
- Edinburgh Air Charter Flight 3W (September 1999)
- Korean Air Cargo Flight 8509 (December 1999)
- Loganair Flight 670A (February 2001)
- British Airways Flight 268 (February 2005)
- Loganair Islander accident (March 2005)
- Morecambe Bay Eurocopter AS365 crash (December 2006)
- Alderney UFO sighting (April 2007)
- British Airways Flight 38 (January 2008)
- Biggin Hill Cessna Citation crash (March 2008)
- Vauxhall helicopter crash (January 2013)
- CHC Scotia Flight 23R (August 2013)
- Glasgow helicopter crash (November 2013)
- Haughey Air AgustaWestland AW139 crash (March 2014)
- Loganair Flight 6780 (December 2014)
- Blackbushe Phenom 300 crash (July 2015)
- Shoreham Airshow crash (August 2015)
- Leicester helicopter crash (October 2018)
- Gatwick Airport drone incident (December 2018)
- English Channel Piper PA-46 crash (January 2019)