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
ayDepartment 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
wCONTENTS
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
2912
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 BASSAWY21
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
153Figil
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
iyFIG 1: SHOWING CAir 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 redderWithin 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 theIndications 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 thecommander 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 ed4.2
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 1988ying 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 aireraf153
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:
101.6
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
n162
163
1.6.3.1
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
216.3.2
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