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AIRCRAFT ACCIDENT REPORT 4/90 a Air Accidents Investigation Branch i Department of Transport Report on the accident to Boeing 737-400 G-OBME. near Kegworth, Leicestershire on 8 January 1989 Oe LONDON : HMSO. LIST OF RECENT AIRCRAFT ACCIDENT KEPORIS ISSUED BY AIR ACCIDENTS INVESTIGATION BRANCH 189 Ainmiss be ween Tristas G-BBAB and February 1989 “Tupolev 154 L2-BTE near Lydd, Kent fon 6 Februnry 1988 2189 “Incident involving BAC 1.11 G AYWB and May 1989 ‘Boeing 737 ELBTZ at Gatwick Airport ‘on 12 Apri 1988 3189 Sikorsky S61N helicopter G-RDI nese Handa Sune 1989 Island off the north-west coat of Scoland ‘on 17 October 1988 4189) Boeing 747 N6OSPE at Gatwick Aiport August 1989 on | February 1988 5/89 ‘Bowing 747-136 G-AWNM on approach 10 Desemter 1989 ‘Runway 27L at London (Heathrow) Airport ‘on 11 September 1988, 6189, Concorde 102 G-BOAF over dhe Tawi Sea, December 1989 about 140 nm east of Sydney, Austin (on 12 Apeil 1989 190 ‘Siorsky S6IN G-BDES in the Noch Sea ‘May 1960 ‘90mm north-east of Aberdeen ‘on 10 November 1988, 280, Being 747-121, NT39PA at Lockerbie, Dumfriesshire, Seotand con 21 December 1988 390 Sikorsky S6IN, G-BEID 29 nmnorth east ‘of Sumburgh, Shetland Isles on 13 July 1988 480, Boeing 737-400, G-OBME. near Kegworth, Leicestershire fon 8 January 1989 ay Department of Transport Air Accidents Investigation Branch Royal Aerospace Establishment Farnborough Hants GUI4 6D 25 August 1990 ‘The Right Honowrable Cell Parkinson Secretary of State for Transport sir, have the honour to submit the report by Mr E J‘Trimble, an Inspector of Accidents, on the circumstances ofthe acident to British Midland Airways Boeing 737-400, G-OBME, which ‘occured near Kegworth, Leicestershire, on 8 January 1989. have the honour to be sir ‘Your obedient servant DA COOPER (Chief Inspector of Air Accidents w CONTENTS GLOSSARY OF ABBREVIATIONS SYNOPSIS 1 FACTUAL INFORMATION 1.1 History ofthe might 1.2 Injuries persons 1,3. Damage o srerat 1.4 Other damage 1.5 Personnel information 13.1 Commander 15.2 First Officer 13.3 Cabin Amendants 1.6 Aireraf information 1.6.1 Leading paniculars 1.6.2 Description of engines 1.6.3 Engine instrument system (EIS) 1.6.4 _Aithome vibeation monitoring (AVM) system 1.6.5 Engine ire and overheat detection system 1.6.6 Airconditioning system 1.6.7 Cabin floor structure 1.68 — Seats 1.6.9 Overhead stowage bins 1.6.10 Maintenance ecords 1.7 Meteorological Information 1.8 Aids w navigation 1.9 Communications 1.10 Aerodrome information LLL lightrecorders LLL Flight Data Recorder (FDR) 1112 FDR data analysis 1.113 Cockpit voice recorder (CVR) 1.11.4 — CVR wanscrpt significant events LILS —CVR frequency analysis, (wil) ai 2 2B 23 2B 7 2 29 12 113 1s Las Lin ‘Wreckage and impact Information A 122 On site Subsequent detailed examination ‘Mesical and pathologic! Information BA Injures 1.132 Types of injury Fi Survival aspects 1 1 15.1 152. ‘On-board emergency preparation and impact effects Rescue operations “Tests and research i 1 1 i 1 16.1 162 163 164 165 Engine tests to identify the cause of fan bide fatigue “Trials to establish fuel leak characteristics ‘Tests ofthe engine instrument system (EIS) KRASH computer simulation Computer simulation of occupant response Additonal information 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 I 172 173 ina 115 17.6 117 178. 179 17.10 171 1712 17.13 17.14 17.15 17.16 1717 1718 17.19 17.20 Plot raining ‘The aircraft Operating Manual and checklist, Pilot opinion ofthe EIS Engine vibration monitors in arraft Actions by Ait Trafic Contol Development ofthe CFMS63 engine ‘Sulbsequent fan Blade fractures on Boring 737-40 aierat Incidents involving fan blade damage from bird ingestion Fatigue ination and growth (Cracked fan die ‘Changes in seat and cabin structural requirements (Crash dynamics research Afifacing sets Child restrain systems ‘Loading of overbead stowage bins Requirement for fuel tank protection Other survivable accidents ‘Analysis of deceleration data ‘Aiore closed circuit television monitoring ‘AAIB Special Bullesn $2/89 1.18 Now investigation techniques iit) gee Bee R SELSSSSSSSHRRLVSSSRAS BASSAWY 21 22 23 2 25 26 ANALYSIS Crew actions 2.1.1 Thereaction ofthe fight crew to the engine problem 2.1.2 Crew co-operation 2.1.3 Theinfluence of stress 2.1.4 Flighterew taining Engine failure analysis, 2.2.1 General 2.22 Nol engine failure sequence 2.2.3 Cause of fatigue ination in fan blade No 17 2.2.4 Source of vibratory stresses 2.2.8 Failure ofthe cenificaton process to reveal vibration Fie 23.1 Source of fire 2.3.2 Potential eects of fire 2.3.3 Fuel tank integrity Aircraft systems 24.1 Aircraft systems - general 2.4.2 Airconditioning system 24,3. Engin fire and overheat detection system 2.4.4 Performance of the AVM system 24,5 Engine instrument system 2.4.6 Airbome close circuit television monitoring light recorder design requirements ‘Survival aspects 2.6.1 Injures 2.62 Occupant simulation 2.63. Assessment of deceleration 2.64 Seating 2.65 _Alemative seating configurations 2.6.6 Cabin floor structure 2.6.7 Fature floor requirements 2.6.8 Infant and child restrain systems 2.69 Overhead stowage bins (ix) 105 107 108, an nm 3 7 ug 9 120 120 m 123 124 124 124 124 125 126 27 128 129 129 130 BI 132 135, 37 138 138 139 ‘CONCLUSIONS 3¢@) Findings 3(b) Cause SAFETY RECOMMENDATIONS APPENDICES Appendix 1 Fig Fig? Fig3 Buract 1 Fig 40,0) Fig5 Fig6 Fig? Figs Appendix 2 Figl Fig? Fig3 Fig Figs Appendix 2.6 Appendix 2.7 ‘Appendix 2.8 Appendix 3 Fig Fig? Fig3 Fig Figs Fig6 Fig7 Figs Figo Fig 10 Engines Engine cross-section Fan assembly damage (C-OBMB) “Microsection though fatigue origin on blade 17 JAR and FAR blade vibration requirements Fan assembly damage (G-BNNL and G-OBMG) Fan blade fatigue fracure (G-OBME) Fan blade fatigue fracture (G-BNNL) Fan blade ftigue facture (G-OBMG) ‘Comparison of fan blade fatigue fracture lines. Systems Boeing 737 ight deck with hybrid EIS Boeing 737 flight deck wih solid-stae EIS Solid-state electronic EIS Location of fre/overbeat detection elements Air conditioning system schematic AVM interrogation read-out fr las 20 fighs Engine instrument system assessment Latch up condition Structures and Computer Impact Simulation Seat-rac, forward fuselage ‘Seat-ack, af fuselage (G-OBME seating configuration Passenger ripe seat ‘Overhead stowage bin attachments Impact sequence Seroctural disruption Passenger seat damage summary Seat 31 (Area Seat 1SL (Areal) co) 142 142 148 149 153 Figil Fig 12 Fig 13 Fig 4 Fig 15 Fig 16 Figi7 Fig 18 Fig 19 Fig20 Fig2 Fig 22 Fig23) Fig24 Appendix 4 Figt Fig? Fig3 Appendix $ Fig! Fig? Fig3 Fie4 Figs Fig Appendix 5.7 Appendix 6 Sea ISL (Area TID Seat 28 (Area I Seat251 (Area TV) Floor structure at Staton 867 (Area IV) Floor panel fasteners (Area IV) Floor beam a Staton 807 (Area IV) Seat rack at Station 727D (Area TI) Seat track and Seat SR (Area 1) Seat track and seat 3 (Area) Floor beam at Station 460 (Area 1) (@)Stowage bin tachments () Stowage bins KRASH develerations - Run 2 KRASH deceleratons - Run 3 Other survivable accident - smmary Flight Recorders Block diagram of EIS signal path G-OBME tack plot FDR engine parameters record FDR engine vibration record FDR engine parameters at Event | FDR final ight parameters record ‘G-OBME final ight pa CVR area mic frequencies before/after Event 1 CCVR area mic frequencies before/after Event 2 FDR intial engine parameters comparison(G-OBME: G-BNNL: B-OBMG) Variation of throtle lever angle during Event 1 Injuries and computer occupant simulations Seat position of fatalities and survivors Injury severity scores (ISS) of occupants Distribution of injury extent (ISS *<16) ‘Occupant displacement simulation (braced, lap belt) ‘Occupant displacement simulation (ap +upper torso restraint) ‘Occupant displacement simulation (ft-faing standard seat) References AAIB Special Bulletin $2/89 (xi) GLOSSARY OF ABBREVIATIONS AAIB {Air Accidents Investigation Branch ARS Airport Fre Service ael ‘Above ground level amsl ‘Above mean sea level APU ‘Auxiliary Power Uni ATA ‘Air Transport Association Are ‘Air Traffic Control AVM ‘Airborne Vibration Monitor cD Binary coded decimal BCAR British Civil Airworthiness Requirements BITE Built in Test Equipment BMA, British Midland Airways. CAA, ‘Gil Aviation Authority CAML Givil Aeromedical Intute CAS Calibrated Airspees CATO Givil Air Traffic Organisation ca (Centre of Gravity ac (Cranfield Impact Centre ew Controlled Impact Demonstration cvR Cockpit Voice Reconder EAS Equivalent Airspeed EGT Exhaust Gas Temperature EIS Engine Instrument System EMA East Midlands Airport, EUROCAE European Orgunisition for Civil Aviation Electonics FAA Federal Aviation Adminstration FDAU ——_FlightData Acquisition Unit FDR light Data Recorder TF Fuel Flow FL. Flight Level FMS light Management System FOD Foreign Object Damage fps Feet per second FSM Flight Service Manager ft Feet or foot z ‘Acceleration due gravity GE General Elecvic GPWS Ground Proximity Waming System Hg Mercury (Chemical Symbol) HIC Head Injury Criteria HP, High Pressure | HPC High Pressure Compressor HPT High Pressure Turbine AM Institute of Aviation Medicine Is Instrument Landing System Iss Injury Severity Score sil) MATS: NATS Joint Airwomhiness Requirements Kilogram(s) Suess Intensity Factor Suess Concentration Factor Knots London Air Traffic Contol (Cente) Leading Edge Light Emining Diode Low Pressure Low Pressure Compressor Low Pressure Turbine Mean Aerodynamic Chord Miliary Aie Traffic Organisation Manual of Aie Trai Services Milibas) ‘Main Engine Control Mega Hertz ‘Main Landing Gear Maintenance Manual ‘Master Minimum Equipment List Fan Speed High Pressure Compressor Speed [National Air Trafic Service "Non Directional Beacon, "Nauta miles ‘Outside Air Temperature (Outlet Guide Vane Power Lever Angle Power Management Controller Pressure sting to indicate height above mean sca level Royal Aerospace Establishment Royal Air Force Random Access Memory Rescue Coordination Cente Revolutions per minute Ratio Telephooy Scanning Electron Microscope Societe Nationale dBtude et de Construction de Moteurs Aviation ‘Thermal Aniice oval Ait Temperature “Top of Descent Universal ligt Data Recorder Universal Time Coordinated Variable Bleed Valve Very High Frequency Very High Frequency Omni Range Variable Stator Vane iy FIG 1: SHOWING C Air Accidents Investigation Branch Aireraft Accident Report No: 4/90 (EW/C1095) Registered owner Kommanditbolaget 11, Malmo, Sweden, Operator: British Midland Airways Lid Aircraft Type: Boeing 737 Model Series 400 ‘Nationaliy: British Registration: G-OBME Place of accident: nm eas of East Midlands Airport Latitude: 52° 49° 54" N Longitude: 001° 20 54"W ate and tine 8 January 1989 at 2025 hrs Allsimes inthis repor are UTC SYNOPSIS ‘The accident was notified to the Air Accidents Investigation Branch during the evening ofthe 8 January 1989 and the investigation was initiated on-site at 0040 hours on the moming ofthe 9 January. The AAIB Investigating Team comprised Mr EJ Trimble (Investigator in Charge), Mr 1D Payling (Operations), Mr C G Pollard (Engineering, Powerplant), Mr SW Moss (Engineering, Systems), Mr R D G Caner (Engineering, Structures), Wing Commander D ‘Anton, RAF Insite of Aviation Medicine (AM) (Survivability), Mr PF Sheppard and Miss A Evans (light Recorders). In addition Mr R Green, Head ofthe Psychology Department of the RAF IAM, was co-opted to investigate the human factor aspects of this accident and CCapian M Vivian ofthe Civil Aviation Authority (CAA) Fight Operations Department was co- ‘opted to assist the final assessment ofthe operational aspects G-OBME left Heathrow Airport for Belfast at 1952 hrs with 8 crew and 118 passengers Gncluding 1 infant) on board, As the aircraft was climbing through 28,300 fet the outer pant ‘of one blade in the fan of the No 1 (left) engine detached, ‘This gave rise to a series of, ‘compressor stalls in the No I engine, which resulted in airframe shuddering, ingress of smoke nd fumes tothe flight deck and fluctuations of the No 1 engine parameters, Believing thatthe [No 2 engine had suffered damage, the crew throated that engine back and subsequent shut t down, The shuddering caused by the surging of the No 1 engine ceased as soon as the No 2 ‘engine was thotled back, which persuaded the crew that they had dealt correctly with the ‘emergency. They then shut down the No 2 engine, ‘The No 1 engine operated apparently normaly afer the inital prio of severe vibration and during the subsequent descent ‘The crew initiated a diversion to East Midlands Airport and received radar direction from air trafic control to position the sircraft for an instrument approach to land on runway 27. ‘The spproach continued normally although with a high evel of vibration from the No 1 engine, unt an abrupt reduction of power, followed by a fire warning, occured on this engine at a point 24 1m from the runway. Efforts to restart the No 2 engine were not sucessful. “The sirrat initially struck afield adjacent to the eastern embankment of the M1 motorway and then suffered a second severe impact on the sloping western embankment ofthe motorway. 39 pastengers died in the accident and further 8 passengers die later from ther injuries. Of the other 79 occupants, 74 suffered serous injury ‘The cause ofthe accident was thatthe operating crew shut down the No 2 engine after fan bade had fractured inthe No I engine. This engine subsequently suffered a major thrust loss due to secondary fan damage after power had been increased during the final approach ro land, ‘The following factors comtibuted tothe incorect response ofthe light ere: 1. The combination of heavy engine vibration, noise, shuddering and an associated smell of fire were ousie their waning and experience. 2, ‘They reacted to the initial engine problem prematurely and in away that was contrary to their raining. 3, They id nof assimilate the indications on the engine instrument display before they throtled back the No? engine. 4. As the No 2 engine was throted 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 iad emanated from the No 1 engine and hich had been observed by many on board, including 3 cabin atendants in the aft cabin, 31 Safety Recommendations were made during the course ofthis investigation, FACTUAL INFORMATION History of the flight ‘The sireraft was engaged ona double shutle between London Heathrow Airport, and Belfast Aldergrove Airport It landed at Heathrow at 1845 hrs on completion ofthe frst shute flight and took off again for Belfast at 1952 hrs, with the first, officer handling the aircraft. Afier take-off the aircraft climbed initially 1 6000, feet where it levelled-off above a layer of stratocumulus cloud for 2 minutes, before receiving clearance o climb to flight level (FL) 120. Soon afterwards, at 1958 hrs, clearance was passed to climb to FL. 350 on a direc track tothe very high frequency orni-range beacoa (VOR) at Trent. ‘41 2005.05 hs, asthe sireraft was climbing through FL283 some 20:nm south- south-east of East Midlands Airport, the crew experienced moderate to severe vibration anda smell of fre. The area microphone forthe cockpit voice recorder (CYR) picked up a sound of vibration or ‘rating’ at this ime and the ight data recorder (FDR) showed significant fluctuations in lateral and longitadinal scecleratios. There was no fre warning or any other visual or aural warming on the flight deck. The commander stated afterwards that he saw and smelt air conditioning smoke. The first officer later remembered only a sttong sell of During. Replay of the FDR showed that severe vibration had occurred in the No 1 (eft) engine at this ime, accompanied by marked uetuations in fan speed (ND), rise in exhaust gas temperature (EGT) and low, fluctuating, fuel flow. “The commander took contra of the area and disengaged the autopilot. He later stated that he looked atthe engine instruments bat didnot gain from them any clear indication ofthe source ofthe problem. He als later stated that be thought thatthe smoke and fumes were coming forward from the pasenger cabin, which, from his eppreciation ofthe aircraft si conditioning system, led him to suspect the No? (ight) engine, ‘The fist officer also suid that he monitored the engine instruments and, when asked by the commander which engine was causing the trouble, he said ITS THE LE ... ITS THE RIGHT ONE, to which the commander responded by saying ‘OKAY, THROTTLE IT BACK’. The autothrotte was then disengaged and the No ? engine was throtled back. ‘The first officer later had no recollection of what it was he sav on the engine instruments that led hm to make his assessment ‘The commander's instruction throttle back was given some 19 seconds after the onset ofthe vibration when, according to the FDR, the No 2 engine was operating with steady engine indications. During the 11 seconds that elapsed between the disengagement of the autopilot and the throting back ofthe No 2 engine, the aircraft rolled slowly to the left through 16 degrees but the commander made no corective movement of leon or redder Within 1t02 seconds ofthe closure of the No 2 throttle the srcraft rolled level ‘gain, the Muctuations in lateral and longitudinal accelerations ceased, the No 1 engine fan speed settled ata level 3% below its previous stable speed, and the EGT stabilised at 50°C above its previous level. These engine parameters remained fairy stale for further minute until the commander reduced power on that engine for the descent. However, the indicated vibration remained at ‘maximum and the indicated fue! flow behaved eratially. The commander later ‘tated thatthe ation of closing the No 2 engine throtereduced the smell and the Visual sigs of smoke and that he remembered no continuation ofthe vibration after the No throtle was closed. Immediately after trotting back the No 2 engine, the fs officer advised London Air Traffic Control (ATCO) that they had an emergency situation which looked like an engine fre. ‘The commander then ordered the first officer: ‘SHUT IT DOWN. This order was given 43 seconds after the onset ofthe vibration bu its execution was delayed when the commander sud ‘SEEMS TO BE RUNNING. ALRIGHT NOW. LETS JUST SEE IF IT COMES IN. The shutdown wi further delayed a5 the fist officer responded to radio messages from LATCt ‘hich advised the erw of the areas position and asked which altemate airfield they wished to go to. The first officer said that it looked as if they would take it to Castle Donington (East Midlands Airpor) but LATCC were to stand by. At bout this time flight attendant wsed the cabin address system to advise the passengers to fasten thei seatbelts, The fist officer then told the commander that he was about to star the Engine Failure and Shutdowa’ checklist, saying at the same time ‘SEEMS WE HAVE STABILISED. WE'VE STILL GOT THE ‘SMOKE’. Again, action on the checklist was suspended a the commander called British Midland Airways (BMA) Operations at East Midlands Airport to advise his company ofthe situation. 2 minutes 7 seconds after the star ofthe vibration and during a short pause in radio communications with BMA Operation, the fue cock (start lever) of the No 2 engine was closed and the auxiliary power unit (APU) was started. Shorily afterwards BMA Operations transmitted to the aircraft DIVERT TO EAST MIDLANDS PLEASE’ ‘The commander later recollected that, as soon as the No 2 engine had been shut down, all evidence of smell and smoke cleared from the Might deck, and this finally convinced him thatthe action he had taken was corect. Shorly afterwards power was further reduced on the No I engine, which continued to operate at reduced power with no symptoms of unserviceability other than a higher than ‘normal level of indicated vibration and increased fuel flow. This high level of vibration continued fora further 3 minutes and then fell progressively uni it reached a level of? units onthe cockpit indicator, sil litle higher than normal, ‘Alter the scident, the commander stated that during the remainder of the light the Indications that he had from the engine instruments, or any other source, were such as to indicate tha the emergency had been successfully concluded and that the No | engine was operating normally. In the cabin, the passengers and the cabin atendants heard an unusual noise accompanied by moderate to severe vibration, Some passengers were also aware ‘of what they described as smoke, but none could describe is colour or density ‘They described the smell of burning as rubber, ‘il! and ‘hot metal’. Many saw signs of fire from the left engine, which they described variously as ‘ire’ “torching' or ‘sparks. Several ofthe cabin attendants described the nose as & low, repetitive thudding, ike a car backfiring’, and one described how the shuddering shook the walls ofthe forward galley. ‘The thee flight attendants in the rear ofthe cabin saw evidence of fire from the No engine, and two of them briefly saw light coloured smoke in the cabin. Soon after the No 2 engine was shut down the commander called the flight service manager (FSM) to te ight ddeck and asked him ‘DID YOU GET SMOKE IN THE CABIN BACK ‘THERE?, to which the FSM replied ‘WE DID, YES: The commander then instructed the FSM to clear up the cabin and pack everything away. About one minute later the FSM rere to the light deck and said'SORRY TO TROUBLE YOU. . THE PASSENGERS ARE VERY VERY PANICKY’, The commander then broadcast to the passengers on the cabin address system that there was twouble withthe right engine which had produced some smoke inthe cabin, that the engine was now shut down and that they could expect to land at East Midlands Airport in about 10 minutes. The Might atendants who saw signs of fire on the left engine later stated that they had not heard the commander's reference tothe right engine. However, may ofthe passengers who saw fire from the No 1 engine heard and were puzzled by the commanders reference 19 the right engine, but none brought the discrepancy to the attention ofthe cabin crew, even though several were aware of continuing vibration, The smell of smoke, however, had dissipated by the time the commander made this ‘The No 2 engine was shut down approximately 5 nm south of East Midlands Airport. Having cleared the irra to tur right and descend to FL 100, London ATC passed control to Manchester ATC, who pasted headings to steer for the aircraft to descend to the noxth of East Midlands Airport (EMA) and wo fly to the centreline ofthe lcalizer of the instrument anding sytem (ILS) for runway 27 During the descent the commander did not r-engage the autopilot but flew the aircraft manually, whilst the first officer dealt with radio communications. Flight eck workload remained high asthe first officer obtained details of the actual ‘weather at East Midlands and attempted without sucess to programme the flight ‘management system to display the landing pattern at East Midlands, This lat activity engaged the first officer's atention for 2 minutes. At 2012.28 hrs the commander attempted to review their situation, saying ‘NOW WHAT INDICATIONS DID WE ACTUALLY GET (TT) JUST RAPID VIBRATIONS, IN THE AEROPLANE - SMOKE... His dscassion with the first officer was then interupted by ATC messages passing a new radar heading, further descent clearance to FLA0 and intruetions forthe areaft to change radiofrequency to ast Midlands (Castledon) approach control. As soon as contact was established ‘on the new frequency the firs officer began to read the one-engine inoperative ‘descent and approach checklist. Radio calls again interrupted this activity when the Castledon approach controler asked the commander to make atest ell 9 the serodrome fire service, which e did, bat received no response. The approach ‘checklist was finally completed at 2017.33 hrs, when the aircraft was 15 nm from touchdown, descending through 6,500 feet above mean sea level (ams). One ‘minute ater the commander aeceped anew radar vector of 220° to take the seat, south ofthe extended runway centrelin in order to increase his distance from touchdown, and shorly afterwards called forthe wing flaps to be selected to 1 ‘Throughout the descent there were distractions fom a small number of other ieraft making radio calls on the same frequency’ as that being used by G-OBME, ‘When the airraft was 13 nm from touchdown on this new heading, and descending to 3,000 feet ams, ATC advised aright tur to bring the aircraft back tothe cenreline. At 2020.03 hrs, during this tun, power was increased on the [No 1 engine o level the airerat momentarily a 3,000 feet and maximum indicated vibration was aguin recorded on the FDR. The airraft was then cleared 10 descend to 2000 feet and the commander began a slow descent, calling successively for 2° and then S°of fp. After joining the cenreline, at 2000 fect above ground level (ag), the commander called forthe landing gear tobe lowered and, a he passed the outer marker at 4.3 nm from touchdown, called for 15° of| fap. One minute later, t 2023.49 hrs, when the aireraft was 2.4 nm from touchdown at a height of 900 fet agl, there was an abrupt decrease in power from the No I engine. The commander called immediatly forthe fist officer to relight le estat) the other engine andthe frst officer attempted to comply. The ‘commander then raised the nose of the airrat in an effort to reach the runway. 17 seconds after the power loss the fire warning system operated on the No 1 engine and 7 seconds later the ground proximity warning system (GPWS) sldesiope warning sounded and continued with increasing repetitive frequency as the aircraft descended below the glidepath. ‘The commander ordered the first officer not to carryout the fire drill. At 2024.33 rs the commander broadcast rash waming on the cabin address system using the words PREPARE FOR CRASH LANDING’ (repeated). 2 seconds later, a the airspeed fell below 125 ks, the stall warning stick shaker! operated, and continued to operate until the Sik shake —An oii ol waning device tat car th con! columns iat when he ayn ihn toe an of he ml al ed 4.2 sircraft struck the ground at 2024.43 hrs, The las sirspeod recorded on the FDR was 115 kts. No power became availabe fom tbe No engine before the aircraft struck the ground, ‘The inital ground impact was in @nose-high atiude on level ground jus 10 the cast ofthe MI motorway. ‘The treat then passed through tres ad suffered its second and major impact 70 metres to the west and 10 metres lower, on the ‘western (i northbound) carriageway ofthe M1 mocorway and the lower pat of the western embankment. The fuselage was extensively disrupted, and the aircraft came to rest entirely on the wooded western embankment approximately 900 metres from the threshold of runway 27 and displaced SO metres to the north of the extended runway cenreline. Several of the passengers described heavy vibration immediately prior to the {impact and one passenger, inthe rear ofthe aircraft, described the vibration as ‘being severe enough to open the overhead lockers and cause them to spill contents. Passengers in the rear of the aircraft described two distinct impacts; ‘those inthe front appeared only to have been aware of the fina impact. Ground witnesses who saw the final approach saw clear evidence of fire associated with the left engine. The intake area ofthe engine was filled with yellow/orange fre, and flames were observed steaming aft from the nacelle, pulsating in unison with ‘thumping noises”. Metallic ‘ating’ was also heard, and flaming debris was seen flling from the srcraft [After the sreraft crashed, a BMA engineer entered the flight deck ad switched off the main batery switch and the standby power switch. He later returned t9 the ight deck and switched off the engine ignition (engine star switches) and the {uel booster pumps. The engine start levers (uel valves) were found inthe cutoff position. No witness was found who could testify to having moved them, Injuries to Perso Crew Passengers Others Fat sil a Nil Serious 7 66+ Linfamt—Ni Minoenone 1 4 5 firemen suffered minor injures during the rescue operation. 13 14 Ls 1s Damage to aircraft G-OBME suffered severe impact damage and the fuselage broke into 3 main sections (Fig 1). The nose section travelled the greatest distance up the western embankment of the MI, the centre-section remained upright with the wings attached and the tail-section buckled over, and to the right of, that section of| useage just ft of the wing Both engines were found at their wing stations, although they had suffered round impact damage. Most of the components which had separated were found around the impact ste. Several small pieces ofthe No 1 engine were recovered from a site about 3 kilometres to the eas, under the final lightpath Other damage During the crash sequence the rear fuselage underside and main landing gear of the aircraft scraped the surface off a small area ofa gras Field next tothe easter embankment ofthe motorway. The srcraft then demolished a 10 metre section of ‘wooden fencing athe crest ofthe eastem embankment, before cutting a 40 mete _swathe through the tops of tees growing onthe embankment [As the aircraft descended across the carriageways it destroyed one central lamp standard and a detached landing gear leg struck and deformed the central reservation barrie. The aircraft then sid up the western embankment, destoying ‘woes over an area approximately 4 metzes square. Personnel information Commander: Male ged yeas Licene Aine Transport Pilot's Licence fit issued Ragin 1977 vl nel 8 Angst 1997 Aer ratings: Auster, Dakow/C#7, BAC 1-11, Viscount, - DC-9, F 27, Boeing 737 Series 200, 300 and 00 Media erica: Ciass One issued 24 August 1988 with no Siatsons vad unl 31 March 1989 Insert ring: ‘Valu 15 November 1989 Las base check 16 Ocober 198 Last rote heck 12 November 1988 Lastemergencie check: 26 Api 1988 ying experience: ‘Tot all ypes: 13,176 hours Total on BIS: "763 hours ‘Total ast 90 days: 12 hours “Toxalast 28 ays: 12 hours Duty tie: (On leave from 17 December 1988. On duty 1430'hrs 8 January 1989 “The commander underwent initial flying taining at The London Schoo! of Fiying {in 1964/65 before joining BMA in 1966, He was employed a a first officer unit he passed a command course in 1974, and then as a captain successively on ‘Viscount, F27 and DC9 aircraft until 1987, He completed a conversion couse 10 the Boeing 737 Series 300 on 13 December 1987 and a further short course on the Series 400 aireraft on 17 October 1988. He had flown 23 hours on the Series 400 aircraft First Oftcer Male, aged 39 years Licence: Airline Transport Pilot's Licence first issued 12 ‘August 1986 tnd valid until 11 August 1996 Aircraft ratings: PA 28, Cessna 4028, 402C and 408, Shors SD £330 Series100 and 200, Shons SD 360 Series 100 and 200, Boeing 757 Series 20,300 and Medica ceria Class One issued 25 August 1988 with no Timaions, valid uc 31 March 1589 Insert ring: Vat ui 13 Augst 1989 Last base chek 22Decenter 988 tas rout check 5 November 1988, Lastemergencies check: 20Jly 1988 Flying eperience Toa al ype: 3.280 hours : Foal on BSF 102 hours Teal srd0diys: 104 hours Toallist28anys: 37 Rous Duyn: (0m duy 1200 hours 8 January 1989 (postoning toLondon/ esto fom Belst) ‘The first officer underwent fying traning at Simulated Flight Training at Hum [Aigport in 1983, He was then employed by several independent public air ‘ransport companies before joining BMA in 1988, where he was initially employed as a first officer on the Shorts SD 360. He received conversion training on the Boeing 737-300 from his company during June and July 1988. “He was checked as competent to act a5 a frst officer oa the B737 Series 300 on 28 July 1988 and on the B737 Series 400 on 17 October 1988. He had flown 53 hours on the Series 400 aireraf 153 Cabin attendants (listed inorder of joining BMA) Flight Service Manager: Date joined BMA: Qualified on 8737 Last emergencies check Rest perio before Might: (Cabin atendant 1 Dat joined BMA: Qualified on 8737 Last emergencies check: Rest period before Night: (Cabin attendant 2: Dat joined BMA: Qualified on 8737 Last emergencies check Rest prio before Night: Cabin attendant 3 Date joined BMA: Qualified on B73: Last emergencies check: Rest period before ight: (Cabin atendant 4 Date joined BMA: Qualified on B73 Last emergencies check: Rest period before ight: Cabin atendant 5 Dae joined BMA: Qualfie on B37: Last emergencies check Rest period before fight: Male, aged 27 years May 1986 4 November 1987 S January 1989 14 hours 10 minutes Female, aged 24 years 11 May 1987 20 Apeil 1988 25 August 1988 6hours 0 minutes Female, 27 years 30 March 1988, 25 August 1988 29 September 1988 15 hours 20 minutes Male, aged 29 years 5 October 1988 14 December 1988 21 December 1988 More than 2 ys Female aged 2 years 23 November 1988, 14 December 1988 21 December 1988 19 pours 10 minutes Male, aged 23 years 19 October 1988 14 December 1988 21 December 1988 19 hour 30: 10 1.6 161 Aircraft information Leading pariars Type Contracts maner: Date of Monsgacae. Ceracate of Registration: Cerificate of Airworthiness: Tova airframe hows: Engines (2): ‘Masi weight authorised for take-of Actual take-off weigh: ‘Maximum weight authorised for landing: Esimated weight atte time ofthe accident: Estimated fue remaining at ‘he time of the accident: Centre of gravity (CG) limits ‘aracciden weight: CG at ie of accident: Boeing 737 Series 400, 23867 1988 Registered in the name of British Midland Airways Lid Issued on 3 November 1988 in the Transport Category (Passenger) and valid until? November 1989, S21 (CFM 56-3C high by-pass turbofan engines Nol Serial No 725-127 No2 Serial No 725-130 64,636 kg (142,496) 49.940 kg (110.098 b) 54,884 kg (120,997 1b) 48,900 kg (107,805 1b) 4,210 kg (9.281 1b) 8.27.6% mean aerodynamic chord (MAC) 15.7% MAC n 162 163 Description of engines General features: (See sectional view of engine at Appendix 1, 1) ‘The CFM $6-3C-1 isa two shaft, high by-pass ratio turbofan engine of modular construction, rated at 23,500 Ibs thrust for take-off. The 38 blade fan and 3 stage low pressure compressor (LPC or booster) are driven by four stage low pressure turbine (LPT) powered by the exhaust gases of the core engine. The 60 inch diameter fan produces about 80% of the total engine trust, whichis almost directly related to fan speed (NI). The thrust is regulated by control ofthe core engine which has an annular type combustion chamber anda 9 stage axial flow hgh pressure compressor (HPC) driven by a single stage high pressure turbine (HPT). The fuel and airflow control of the core engine is governed by a ‘Woodward hydromechanical main engine contol (MEC) which, in conjunction ‘withthe clecuonic power management controller (PMC), adjusts the core speed (0X2) t give the fan speeditrust demanded by the plo va the thrust lever. The IMEC and fuel pump are driven by the core engine via an accessory gearbox, ‘mounted on the lower lft side ofthe fan case, which also drives a generator and hydraulic pump to provide electrical and hydraulic power fr aireaft services High pressure aie is bled from the core compressor to provide cabin conditioning and othe sirrat pneumatic services. A brief development history of this engine type is given at paragraph 1.176 Engine instrument system (EIS). ‘The EIS provided a solid-state display of engine-related parameters which replaced the earlier aay of individual hybrid eleco-mechancal instruments with two display units. One unit displayed the primary parameters and the other displayed the secondary parameters (See Appendix 2, figs 1,2. 3). IS primary display ‘The following engine parameters were displayed- fan speed (1) ‘exhaust gas temperature (EGT) core speed (N2) fue flow (FF) “These parameters were presented in both analogue and digital form by the use of light-emitting diodes (LEDs). The analogue presentation utilised 81 bars of LEDs, arranged radially around the outside of each display scale. The bars 2 16.3.2 iluminated one ata time, in sequence, to simulate the movement ofthe end of pointer sweeping around the outside ofthe display scale. Other design features conceming the movement of the LED ‘pointer were also incorporated, inorder to ‘mimic the behaviour ofa elcto-mechanicl indicator. “The digital presentation, which was common to both the EIS and the earlier hnybrd instruments, was situated inthe cente of each indicator and also used LEDs, These simulated the rolling drom mechanism used on conventional clectro-mechanical indicators by making the display digits appear to ol!’ past the viewing aperture, with half of each adjacent digit visible in the last ‘window’ “This preserved the rate and direction of motion cues available othe pilot. Red cexceedance warning lights were positioned above each NI, N2 and EGT display nd were designed to iluminate whilst the affected parameter remained above the ‘recline’ limit. Exceedance information was stored in 4 non-volatile memory Which could be imerrogated by maintenance personnel Both NI displays also featured movable LED cursors to indicate target NI’, ‘hich could be set manually by using two knobs located inthe lower comers of the display bezel, or automatically by the light management computer. When set ‘manually, his information was repeated in digital form in two windows at the top ‘of the display. A batton at the bostom ofthe display bezel was use to change the reading of fuel flow rate wo fuel used. After 10 seconds the displays automatically reverted 10 uel flow’ A three-character display atthe top ofthe primary BIS annunciaed the thrust made as selected through the flight management computer. ‘An ‘abnormal star algorithm was incorporated which would cause the EGT