Kegworth / East Midlands plane crash - 25 years ago

[MarkC]

Another incorrect recollection.

 

Read the accident report and you'll see there is no element of 'autocratic' captaincy in the accident chain. The discovery channel programme on the accident was a mixture of fantasy, make believe and innacuracies. Apart from that it was great.

Mm, I fear we must agree to disagree on this one. It was the start of the now accepted challenge & response procedure as part of Cockpit Resource Management. Pity it wasn't being used (as it should have been) on the bridge of a certain cruise ship fairly recently, the same basic management tools now being used at sea too...

 

...but I digress

[Paperlad]

If I may, I would like to add some background information for the benefit of anyone reading this thread.

 

I have previously worked for Midland, although it had changed to BMi when I joined, and the Kegworth crash was still a hot topic for flight deck and crew room discussion. There is a great deal of 'peripheral detail' that was not included in the accident report as it was not part of the, hard, factual detail that can be recovered from the FDR or CVR but was more personal interaction, opinion or conjecture.

 

The event was primarily responsible for the introduction of, formalised, CRM (Crew Resource Management) training for all crew members, not only flight deck. CRM training is now a legal, world wide, requirement for the issue of a multi crew pilots licence and requires annual, refresher training. Although some countries are better than other at embracing true CRM the Kegworth event is still used, around the world, for CRM instruction.

 

Additional pilot training was introduced, post Kegworth, when changing from one aircraft type to another one of the same type but different series. The 737-400, although outwardly, very similar to the, earlier, -300 series was a very different aircraft. It had substantially different engine instrument displays and a new air conditioning/pressurisation system, both contributing factors in the pilot decision process. When the -400 was introduced at Midland the only extra training for type rated -300 pilots was 4 or 5 hours classroom study and any additional home study a pilot chose to undertake, then you were good to go. All seems a bit Heath Robinson now but they were the accepted standards of the day. Additional simulator training is now required.

 

Air traffic control services also received additional recommendations mainly with regard to reducing/removing any non essential radio transmissions to an aircraft in distress and also to remove routine calls to other traffic by providing alternative frequencies.

 

Further manufacturing and maintenance procedures were also introduced as high engine vibration had been reported by previous crew flying the incident aeroplane but engineers were unable to replicate the problem on the ground. Despite attempts to diagnose the cause of the vibration the aircraft continued in service. I have, in the back of my mind, a memory that there was a second -400 fan blade failure, at another operator, that caused the grounding of all -400's but I may be wrong with that bit.

 

Proper accident investigation should never be about blame but about learning, however, in my opinion, this is being diluted by our love of litigation and lack of personal responsibility.

 

The safety record of the British aviation industry remains the envy of the world, in part, because we are able to learn from tragic events, like Kegworth,

[Pacific231G]

Mm, I fear we must agree to disagree on this one. It was the start of the now accepted challenge & response procedure as part of Cockpit Resource Management. Pity it wasn't being used (as it should have been) on the bridge of a certain cruise ship fairly recently, the same basic management tools now being used at sea too...

 

...but I digress

Though there seems no particular evidence of "autocratic" captaincy in the public enquiry report it does include this paragraph. 

 

"It was the worst of bad luck that he (Second Officer Keighly) should have been in the P2 seat on this occasion. His witnessing

of the crew-room incident between Captain Key and F/O Flavell can have done nothing but harm to

his self-confidence. It may well have given him an alarming impression of the Captain with whom

he was about to fly. His natural tendency towards self-effacement would not have encouraged him to

question the actions of his Captain without serious deliberation, particularly a Captain with whom

he had never flown before, and his slower than average reactions would probably not have been a

match for the sudden and alarming events on the flight deck. It would be a harsh judge who would

criticise S/O Keighley for anything he did or failed to do in these circumstances."

 

This implies, as Mark suggested, a general culture of autocracy even if Captain Key wasn't particularly guilty of this. The fairly lively discussion about this on PPRUNE - which for once seems to be between people who flew with BEA at that time- seems to confirm this.

The introduction and development of CRM has been one of the major milestones in improving aviation safety and I've no doubt that applies equally at sea though Mark would know more about that. 

It's also important to note that the lessons learnt from an accident aren't just from finding the actual causes. Often the possible causes can be just as revealing.

[Edwin_m]

Further manufacturing and maintenance procedures were also introduced as high engine vibration had been reported by previous crew flying the incident aeroplane but engineers were unable to replicate the problem on the ground. Despite attempts to diagnose the cause of the vibration the aircraft continued in service. I have, in the back of my mind, a memory that there was a second -400 fan blade failure, at another operator, that caused the grounding of all -400's but I may be wrong with that bit.

The AAIB report refers to two other blade failure incidents which were almost identical to the initiating incident at Kegworth, both in the circumstances and the nature of the failure.  One of these provided evidence that if slightly less power had been demanded the damaged engine would possibly have continued to run nearly normally.  The cause was that design changes to the engine introduced an unexpected vibration which hadn't been tested for.  No grounding was mentioned in the report but this may have happened later. 

[Pacific231G]

I note you selectively quote the bit of the report after the paragraph on the second officers capabilities and personal development. .....

I'm aware of that other discussion, and I've read the authors book. Have you? its 'entertaining', and I know a couple of people who flew from that era having worked with them.

 

I'm personally more than aware of accidents/learning/causes and possibilities. I've seen three accidents, seen helicopter wreckage that tells you what happened to the pilot before the investigation has started, and lost two people I knew to aircraft accidents. Such is the price of working professionally in aviation for 30 years.

I quoted that paragraph because it's the one that suggests that an inexperienced SO might have been unwilling to question the actions of the Captain. There was no implication that Key was particularly autocratic but my understanding of CRM is that cross checking of each others' actions is now the norm for multi-pilot flying, not something that would require particular confidence on the part of a junior crew member. 

I've not read the book written by "blind pew" (a contributor to the PPRUNE aviation forum who had a lot to say about the Staines accident) and probably won't. I'm afraid my flying reading tends more towards Langewiesche than airline pilots' autobiographies.

I've also witnessed four aircraft accidents, fortunately non fatal but definitely in the I Learnt About Flying From That category.

[MarkC]

Mark, with respect Staines was not a significant player in the start of Crew Rescource Management. It couldn't be, there were no cockpit recordings so no-one knows what happened in the cockpit.

 

As I suggest read the report, the report specifcally states there was no evidence to that effect. You may be getting confused that the Staines accident was the key in getting mandatory voice recorders fitted into UK registered commercial aircraft above a certain weight.

 

There was one particular accident that led to CRM development.

UAL173 at Washington

The investigating team at this accident noted the similarities between Eastern Airlines flight 401 (1971?) and KLM + PanAm at  Las Palmas 1977. This is where CRM started, not Staines. Unfortunately there are a number of recent accidents in aviation too where the concept still hasn't been adopted by those first at the scene of the accident.

Agreed, CVRs were not being used - however, the 'my way or the gangway' attitude of the Captain was well known amongst aircrew, and has been commented on regularly over the years. Combining that with the information that was available in the aftermath led to previous documentaries & investigations concluding that it was certainly a possibility as a cause.

 

Whilst Staines wasn't a major key to introducing CVRs/CRM to aviation, it is still referred to as an example of how things should not be done, and will have been a factor when working up the reasoning as to why these things should be introduced, as they are expensive, & airlines and shipping companies don't like spending money unless they have to...

[Pacific231G]

 

 

Whilst Staines wasn't a major key to introducing CVRs/CRM to aviation, it is still referred to as an example of how things should not be done, and will have been a factor when working up the reasoning as to why these things should be introduced, as they are expensive, & airlines and shipping companies don't like spending money unless they have to...

Agreed. As with railway safety there's often a particular accident that really seems to trigger a major change but those changes are usually already in the pipeline even if not yet accepted. It would be very unusual for a single accident to lead to a major change in operating practice based on it alone though that does occasionally happen.

[steveb860]

Is it really 25 years ago. I was in a pub in Dumfries when this came on the news. It was news that stunned us as we were deployed from RAF Stafford to gather up the wreckage of PanAm flight 103 when this happened. Half of the recovery specialist from RAF Abingdon had to redeploy to deal with this. A time of my life I try to forget.