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Posted By Jim Walker
Can anyone point me to a good technical report on this.
I want to use it in a training session to illustrate human /machine interfaces and how they can cause accidents.
I believe the cockpit readings were telling the pilot things were worse than they actually were - but no-one thought to look out of the window and check.
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Posted By John Ridd
Good example of the need for ergonomics; human error being blamed for what was essentially, as I understand it, poor design and lack of appropriate training on the new aircraft.
Afraid I haven't got a copy but the report is: Dept. of Transport (1990) Air Accident Investigation Branch report on the accident to Boeing 737-400 G-OBME near Kegworth, Leicestershire on 8th January, 1989.
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Posted By Frank Cooper
Jim,
The following may help. I got it from a website dealing with serious incidents some time ago but cannot remember which site!
Kegworth Plane Crash 8 Jan. 1989
Take off Plane climbs to cruising altitude of 28,000 feet.
Vibration suddenly felt, smoke enters cabin.
Major malfunction in one engine.
No clear indication of which engine had failed.
“Flutter” causes damage Closed starboard engine.
Vibration stops.
Wrong engine shut down
Announcement made of problem.
Head for East Midlands airport as a precaution.
No problems Cruising comfortably.
Starts decent.
In for landing Increased power required from engine on landing
approach.
Damaged fan blades sucked into engine.
Port engine explodes.
Crash No engine power available.
Plane loses altitude and hits motorway
embankment.
Hope this helps,
Frank Cooper
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Posted By Ian Waldram
I think it wasn't quite "no one thought to look out of the window", rather that the cockpit crew couldn't actually see the engines, so relied on their instruments. In fact some passengers, and I think cabin crew, DID see which engine it was but assumed the pilots knew what they were doing - and the pilots didn't think to get visual confirmation from these "non-specialists".
This accident is also an example where improved CRM (crew resource management) would have made a difference. The aviation industry is pretty advanced in this area of training, not many others have tried it - it applies especially to team response in emergencies or unusual situations.
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Posted By David Allan
Jim
Good (and cheap)video available from BBC resources at http://www.bbcworldwide.com/vet/default.htm
Fatal Error series - "Taking liberties"
Althought the pilot took the rap as ultimately responsible there were many contributing factors that led him to shut down the good engine and run on the defective one. Human factors, training, design, ergonomics and crew communication all played a part. The crew and passengers who were surprised at the captains actions didn't query (out loud)because they assumed that he captain knew what he was doing.
David
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Posted By John Murphy
Jim.
May I point you in the direction of the (extensive) library at the Emergency Planning College, Easingwold, Yorkshire. please visit http://www.co-ordination.gov.uk/ and link to the college. John Parkinson, the librarian will I am sure, be able to advise.
John
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