How Choosing The Wrong Side Killed 47 People | The Kegworth Disaster
ฝัง
- เผยแพร่เมื่อ 20 ก.ย. 2021
- Donations are never expected but appreciated: paypal.me/miniaircrash
Join My Discord: / discord
737 Image: Pedro Aragão - Gallery page www.jetphotos.com/photo/6016946 Photo cdn.jetphotos.com/full/2/2319...
Crash Site Photos: AAIB
Cluster Image: FAA
737 Cockpit Image: Bill Larkins
This is the story of British midland flight 92, on the 8th of january 1989, a british midlands boeing 737, was to fly from heathrow to belfast international airport with 126 people on board. The plane took off at 7:52 pm and flight 92 first climbed to 6000 feet, then it was cleared up to 12,000 feet and then it was cleared up to its final cruising altitude of 35,000 feet. The 737 climbed to 35,000 feet as the plane flew towards the city of trent. At 8:05 pm as the plane climbed through 28,300 feet the crew felt a bit of vibration and they smelled smoke. In the cockpit they could hear a sort of rattling. But so far the instruments did not show any signs of a fire.
The captain disengaged the autopilot and took control of the plane, he scanned the instruments to see if he could discern what was wrong, he couldn't. He felt that the smoke was coming into the cockpit from the cabin, the captain at this point fell back on his knowledge of the 737. According to the captain the 737’s cabin was pressurized with air from the right hand engine or engine number two. The right hand engine must be the one in trouble. The first officer had been monitoring the instruments and when asked by the captain about which engine was in trouble the first officer said “ its the le-” he stopped mid sentence and said “it's the right one”, the pilots disengaged the autothrottle and pulled engine number two to idle.
This seemed to solve their problems, the vibration eased up and it seemed like the worst of the flight was behind them. After they throttled engine number 2 back they got in contact with london ATC, ATC wanted to know where the crew wanted to divert to. East midlands airport was quite close by and they would be able to get to the airport quite quickly. They contacted british midlands employees at east midlands and they advised the crew to divert to east midlands and with that their minds were made.
As the plane made its way back it was experiencing vibrations higher than usual but all in all the plane seemed to be in okay shape. But in the cabin the passengers could hear thuds and rumblings and they smelled more smoke. The captain at this point made an announcement to the passengers, he told them that they were having issues with the right hand engine and that they'd be landing soon, this confused some of the passengers, they could see flames on the left hand engine.
London ATC handed flight 92 over to Manchester ATC, as the plane approached east midlands. The captinan flew the plane and the first officer handled the radios, both pilots were engrossed in their tasks as both worked to get the 737 back on the ground. The captain wanted to review their situation.he started to say “Now what indications did we actually get? Just rapid vibrations in the aeroplane?” but his inquiry was cut short by ATC giving them a new heading. By the time the 737 was 15 nm from the runway the single engine approach checklist had been completed.
When it was 13 nms away the plane was lining up with runway 27, As flight 92 made that turn they added a bit of power to the left hand engine and the vibrations returned. Fight 92 was asked to descend to 2000 feet. The pilots brought out the flaps first to 2 degrees and then 5 degrees. They also extended the landing gear. The plane descended towards runway 27. When they were 2.4 nm from the runway the plane was at 900 feet and descending. Suddenly there - วิทยาศาสตร์และเทคโนโลยี
A traffic jam on the M25 saved a friend of mine being on that flight. I was driving her to Heathrow to catch that flight to Belfast, but an accident on the motorway delayed us, we got to the airport well after the check in had closed for the flight. For once a traffic jam on the motorway was a good thing.
Wow that was a lucky escape
See! This is the kind of stuff I read the comments for!
I'm so glad your friend was saved from being on that flight. I hope everyone here has a great day. Stay safe!
🙏🛬😪
Thats real luck mate
It's also the crash that illustrates how important it is for passengers to speak up if they think something is wrong. Many people in the cabin noticed that the pilots were talking about the wrong engine, but none of them spoke to the flight attendants. They all trusted the pilots.
This goes beyond aircraft safety: If you see something suspicious, you should raise concerns. Don't assume that others probably know what they are doing. If your concern is unwarranted, they can still dismiss it.
That's just human psychology. Sheep-think. Conditioning not to question authority, even if you see something patently wrong, like fire coming out of an engine. That said, there are those who overdo questioning of authority too, thinking they know better. They're still sheep, they just follow a different herdsman really.
On the other hand though, 99.99% of the time the passenger is wrong.
@@thewhitefalcon8539 That's fine. If there is a 1 in 10000 chance of a serious problem, the crew should know (that's orders of magnitude higher than the background rate).
@@renerpho That sounds fine on paper but you try dealing with 10000 false reports from clueless users all day.
@@thewhitefalcon8539 Well, of course the FA are going to filter out most of the useless stuff. But things like "the pilot says they have a problem with the right engine, while you can see the left engine is on fire" won't be something you'll here 10000 times a day.
Strange but true: the first emergency service to reach the scene of the crash was the RNLI (Royal National Lifeboat Institution) ... a minibus full of lifeboat crew members were heading north on the motorway on their way home from the London Boat Show.
I remember seeing this in real time while working as a truck driver near Nottingham. A moment I will never, ever forget
My heart goes out to you Brother, This was so Tragic.
I was once on a flight and sat next to a BAE systems test pilot who said that the pilot in this crash was his best friend. He told me a few things about the crash but long story short, the pilot was scapegoated and the true full story never came out. Bear in mind that it was pretty much a brand new plane.
Absolutely; why did they turn the wrong engine off - not forgetting the engine failed in the first place. It was brand new aircraft, only 3 months old.
Analog gauges are more readable to me and they also help with the positional memory one has with the analog variety when engines are operating in the normal range. A glance will suffice to imprint the present reading on one's positional memory, if you get my meaning. Your aviation videos are by far the most informative as well as the most enjoyable. Good health to you from the hills of Virginia, sir! You have come a l-o-n-g way! Cork
I was driving south on the M1 in a truck and became aware of less traffic overtaking and then loads of emergency vehicles going north. i think we missed by about 30 - 40 seconds.
Lucky.
Slight note here, which is brushed over: This 737-400 was the first 737 to have air fed via the right engine. All previous versions of the 737 had air fed in via the left engine. British Midland had only had this particular plane for 520 hours, and this change wasn't made clear to the pilots and they didn't receive any simulator training on this new model. So they had, I would say rightly, assumed they were correct in their assumption. Plus the vibration gauges were known to be unreliable, even on Boeing 737 aircraft. The 737-400 was the first aircraft to come with highly accurate gauges. So it was common for pilots to ignore them.
Plus the CFM engines were subsequently found to be incapable of running at the higher power settings required by the 737-400, and had gone into production without being adequately tested. All other 737-400's were grounded and the engines modified before they could fly again. The law was then changed to oblige flight testing of modified engine types.
I'm pretty sure at the time there were reports of new aircraft on the production line being found to have wiring crossed between the two engines, but I can't find a reference now.
To be honest, now I'm reminded of it, it almost looks like a practice run at the 737max scandal. The aircraft was fundamentally unfit to fly, hadn't been properly tested, and included modifications and systems that the pilots were never informed about. But let's blame the pilots.
Aren't pilots usually made to complete simulator trainings on new airplane models? I would hope so. I guess they weren't then. Really tragic. There are usually multiple causes leading up to crashes - not just one.
@@jonathanj8303I've heard airlines often tried to find ways to blame the pilots back then (before the internet and cameras everywhere etc) because the airlines didn't want to be held accountable. It seems like now, investigations at least try to rule out any possibility of pilot errors.
@@scootermom1791 I don't know, but it may the case we do now but not back then.
Just a small correction, the aircraft was heading to the Trent VOR navigation beacon it's named after a local river it's not a town or city,
Great video as always
That explains it
As a professor teaching everything from physiology to philosophy, I want to say how much I appreciate and enjoy these mini crash videos. The contents are clear and precise, and the narrator told the stories in such an engaging and interesting way, without emotional overtone or unnecessary drama. I may be clueless about most of the technical terms, but I am beginning to understand the complexity of these machines and the skills of these pilots to be able to bring us from place to place safely.
Agreed on all points. In addition it makes me feel a lot safer knowing how much redundancy is in place, and how much has to coincidentally go wrong to bring down a commercial passenger aircraft. And also the fact that the industry tries to learn as much as possible from every mistake, which is probably why there effectively haven't been any commercial airliner fatalities in the past decade in the US.
@@R2Bl3nd That statistic always blows me away every time I hear it. 10 years and not 1 fatality! And the last one was that totally freak scenario where an exploding Southwest engine shrapnel just happened to hit a window at the perfect angle to kill the female passenger seated there.
@G K - In general, the technical stuff can be ignored. The question you have to ask in any incident or accident is “Did the people involved set off to do a bad job?” It’s a criminal investigation if the answer is yes. If it’s no, then you have to start asking why those involved ending up doing one. Was it something they didn’t see? What is something someone else didn’t see? Was this new? Were they the right people? Was the training up to scratch? What is the company culture like? Were there problems at home? And so on. So whenever you hear the phrase “Pilot fault” then that is the start of the investigation, not the end.
Aircraft are complex, but not from a flying point of view. The moment you have complexity and people you end up with a lethal combination. Simple people like me fly aircraft. In all but a few occasions, aircraft system failures and problems should be initially handled by DOING NOTHING QUICKLY. You don’t need to rush. You don’t let yourself be rushed. You work as a team and follow the appropriate procure step by step.
It’s not just the skill of the pilots or the perfection of the machines. There’s also a culture to the entire industry (design/manufacture/maintenance/operation). That culture is important. Deviating from it, even with the most noble of intentions (here, let me help you with that...), can and has killed people.
Well said!
I knew somebody whose grandfather walked away from this crash with hardly a scratch. The passengers seated either side of him didn't make it.
Edit: Just looked up the survivor seating plan. He must've been seated at 22E.
2 questions I know people keep asking about this accident:
1. Why didn’t passengers tell the pilots they had made a mistake during the PA?
2. Why don’t planes have cameras?
Answer 1: Most passengers interviewed after said they just thought the captain got his left and right mixed up. Let’s be honest, we’ve all done it
Answer 2: Because cameras have never been the only thing that would have made a difference. Also cameras back then would be big and bulky. The biggest change was the use of “filler gauges” (might be wrong name) where the engine indications make it clearer where the needle is as the area behind is shaded. Also since the A320 and its glass cockpit it tells you in writing which engine has high vibrations or has failed
No i have never made a mistake of left or right.. EVER. But then again i don't get paid a six figure sum for wage's ... I would have spoken up to at least let a crew member know there are flames coming out of the left engine.. !!
Like a pilot would listen to a passenger.
The english people are very polite. It is often a point of humor. The flight attendants should have absolutely reported the fire from the left engine.
On another TH-cam channel (MentorPilot), comments were made that Question 1: Cabin crew were not trained to pass such information on, Question 2: Cameras still are not fitted to 737s.
By the way, that was the end of a bad two weeks. Just before Christmas 1988, PanAm flight suffered a bomb blast over Lockerbie, Scotland. All lives lost. Then Christmas day 1988, my own dad died of a massive heart attack. BM flight 92 just capped off a horrible month.
1. They thought the pilots knew
2. This was before cams were that popular.
Stories like this I think are the reason for many people being afraid to fly. You're in a pressurised tube surrounded by metal, fuel and dozens of other random people and all you can is put your life in the hands of a couple of people you've never met. Sure they're well trained, but even seen multiple times that even well trained people can go brain dead sometimes.
Meanwhile the reason less people are scared of driving, even though we've all heard the "you're more likely to die driving to the airport than on the plane" thing, is because either you personally have control of the car or at the very least it's someone you know and trust.
Plus I guess 100 km/h on the ground is a lot less intimidating to think about compared to 900 km/h in the sky
I remember it coming down, I was an apprentice at the Ratcliffe on Soar power station at the time.
It's somewhat similar to the Transasia crash, right? Where the pilots shut down their working engine instead of the malfunctioning one.
Not to self. When engin problem. Always start the APU
@@matsv201 Virtually Sully's first reaction when both engines failed on that doomed US Airways flight. He 'out-thought' the checklist. Smart move.
Mentour Pilot often talks about the "Swiss cheese model" where a bunch of different things have to line up in just the worst way for an accident to happen. This was some prime Swiss cheese here, just the amount of small mistakes that could have been fixed adding up to something catastrophic
I wanted to mention the Swiss cheese model too, when I read your comment. Indeed it applies here too.
@@yerunski Same here my brother. I was gonna mention the Swiss Cheese Model as well. :)
It's called " Threat and error management" Swiss cheese model is the simplistic way to describe it.
Analog guages are visually comprehendable at a glance while digital guages are more precise.
How about giving a analog look using digital technology? You can have a jet black dial with analog-type display complete with lighted needles and figures both (like a combination of hands and digital display in certain wrist watches).
That is actually what the plane of this crash (Boeing 737-400) had. The Engine Gauges have little LED needles (the Pic given in this Video shows later Gauges the were elongated from what in this incident was used) on the outside with numbers on the inside of the dial to better read the gauge. In this case the vibration was so severe that the needles were washed in vision so that the vibration gauges could not be read easily. But other than that i‘m also in full favor of a mix of steam gauges and digital ones as in the 737 NG.
See my comment above. Have never owned a digital watch. If it ain't broke...
@@luc__0051 I•ron•y _noun_ When you can't read the engine vibration gauges due to excessive vibration
Captain Quirk yea that sure is irony :D But the gauge is normally used to detect minor vibration in the engines that normally dont shake the whole plane. In this case though it was to severe and the small LED needle got washed in sight. Thats why they elongated it to make it easier to read.
Well for one thing not just one pilot is looking at the guages. It would have to be a changeable view as a pilot reaches for one thing or another. Throw in the second pilot and which one is the guage supposed to work for? Also again it would be a projection therefore not interactive with changes in cockpit lighting. Think dusk and sunset during a turn to complicate matters. Things that take hours and hours upon hours of training to get airline level expert at having mental references for. We have slick programming now but that is just another possible failure point. Right?
If there's smoke in the cabin shouldn't the pilots ask the cabin crew to perform visual inspection of the engines? In all of the crash reports before whenever there's a fire that was done!
Shouldn’t the pilots sit in the back where they can see engines control surfaces landing gear and touchdown.
@@brucebaxter6923 Same reason pretty much all animals have their eyes on the front of their bodies, I guess. It'd be harder to see where you're going if the whole plane was in front of the cockpit.
Yes, that is standard preciduer .... now
@@PsychoKat90
Special sort of stupid, aren’t ya.
Why are you going to put the pilots in the fuselage?
@@brucebaxter6923 I guess I'm not understanding the layout you have in mind. There's no need to insult me when you didn't explain what you meant. Outside the fuselage would be... where exactly?
ANALOG & The pilots should have asked the flight attendants to look outside. The flight attendants should have informed the pilots about which engine was in trouble.
If you study air crashes you will find that never happens and never will.
@@willnill7946 Never will ? Why do you think that ? Good CRM (crew resource management) should include the cabin crew too. They can be additional eyes and ears.
The cabin crew did say which engine was sparking. But they were looking rearwards and as a result they too miss-identified the failing engine.
In accidents like these decision bias also plays a great deal role. It's difficult not to have biases but proper training to cross-check could be a potential solution.
Also, pilots are trained for major failures and checklist procedures which takes time and with advancements, in aircraft interfaces, these procedures should be reviewed once too.
This was when glass cockpits were first introduced, and all they did was replicate the gauges. Today, the true power of digital displays is exploited, and caution and warning screens are prioritized before being displayed to the pilot. The computer figures out the worst problems and puts them at the top of the list. In this case, the left engine vibration warning would have been the only thing displayed, and the captain wouldn't have had to rely on past experience.
I just don't understand how they could have designed instrument panels that pilots didn't like and found harder to read. The gauges should have at least been as easy to read as the analog ones, but clearly they failed even at that. They didn't test the panels out with a wide variety of pilots before introducing it into planes? That seems like a gross misstep.
@@R2Bl3ndI understand your viewpoint. There were a variety of factors at play. Larger displays were either very expensive or non-existent. These displays had to be sunlight readable, which is quite exotic, even today. Pilots were vexed by burned out indicator lights, which I believe had contributed to prior crashes. Software gauges did not "stick" like an analog gauge might. Pilots were willing to make trade-offs to get rid of massive wiring bundles and other troubles. It was in its infancy, but everyone knew the glass cockpit was the better way to go. Today, private pilots intentionally tear out their gauges and replace them with displays. That's how much better things got. Basically, it was a minor stumble on the way to superior planes. About half the pilots liked it better, even back then.
Today, with 5 minutes of training, I could teach you to fly a modern jet fighter (not to take off, land, or fire missiles, just to fly it in the air). The plane flies itself now. Back then, pilots were still doing engine management by hand, something that requires real skill, or else the engine stalls, which is a very bad thing.
@@FelonyVideos that's really cool how planes and cars are getting more layers of abstraction in their controls. Rather than directly articulating the control surfaces, now you can just tell planes what you want them to do, like a video game, and they'll just do it. We're seeing much more advanced cruise control in cars, like lane following and things like that. There's no reason for humans to have to manipulate a bunch of complex things in the background, when we can do that with computers now. Just makes me excited for how things will be 20, 30 plus years down the line
@@R2Bl3nd while I share your optimism and excitement for such prospects I can't help but feel wary. I get deja vu, I remember way back some friends being excited how ads will be personalized and you can get a custom shopping experience from all your collected data.. but now look where we are with massive data breaches, personal privacy violation and governments using ai to collate personal collected data that people freely give up to create a "personalized propoganda experience" online, as I like to call it.
No doubt having more abstraction between human inputs and actuation will save countless lives (automated driving, etc) and improve our well-being. We should still emphasize that all this abstraction be done with open source hardware and software and human rights in mind. Already there is possiblity that your smart car could refuse to start up until you watch mandatory 15 minute ads. "But I paid for it why would it have ads?" People said the same thing about cable tv..
@@phxcppdvlazi I share your cautions.
20 years on, I still wear an analog freewheel-powered automatic watch in my left hand and will always do, no matter what fancy smart watches Apple or Samsung or Huawei come up with. Analog wins.
Analog for sure. Seeing the size of a slice of pie, beats digits any day.
As someone who has had thousands of hours in the cockpit before and after the glass cockpit became a thing, I now prefer the digital gauges to the analog because of the quality and quantity of information I can get in a timely matter. That is simply due to the fact that they have become the norm for me now. Not so long ago I would have been of a different opinion. Fifteen or twenty years ago I would take the analog any day of the week. It is a case more of what you are used to and trained on rather then which is truly better in many cases. In fact this incident demonstrates that very clearly.
I think it has to do with, that humans don't like change
Hey what aircraft have you flown in your hours?
It does; the pilots were expected to acquire this new knowldege through flying hours and practice - clearly another error that contributed.
I’ve always been interested in aviation, this channel is like a paradises for me. Congrats on 100k subs!
Love the fact that you referred to Mentour Pilot in your research! Makes it more credible
I think the current US policy of letting airplane manufacturers to test and certify their own equipment is the cause of this crash, along with the poor decision on the engine shut off.
Yeah these engine companies are in it all for profit they don’t give two shits if the engine actually functions or not
@@RedOctober_ If that is true, with thousands of aircraft engines in service every hour of every day, wouldn't there be hundreds of planes raining down from the sky?
@@hrdley911 well if that happened, it wouldn't be profitable because then the engine companies would get in trouble when the crash gets investigated. So they find the perfect balance between good enough to not break all the time but cheap enough so it generates loads of profit.
@@RedOctober_ If a company makes unreliable engines they would go out of business fast - even without any crashes. The airlines really, really want reliable airplanes and are willing to pay top dollar for things that don't break down. Not only does this make their airplanes safer - it also means less schedule interruptions because something broke and an airplane needs to be repaired.
@@RedOctober_ That is not the problem, the problem is that occasionally you get situations when a flaw is found, but the company keeps it quiet while they work on and introduce the fix.
When Turkish Airlines Flight 981 dived to the ground and killed 346, it has happened because of a previously known flaw that almost took down American Airlines flight 96. Now as I said the flaw was known, and Douglas immediately come up with a good fix that would save Flight 981 if implemented. But Douglas also worked a gentleman deal with FFA to allow them to disseminate the needed changes via service bulletin instead of airworthiness directive.
unfortunately, someone, I cant of the top of my head remember which of the previous owners of the plane, half-arsed it and faked paperwork. Which they would probably not have dared, or gotten away with if FAA issued the Airworthiness directive
I've noticed you cover alot of crashes from the Mayday/Air Accidents series but you go into alot more detail about mitigating and aggravating factors. I realize appreciate this because I'm realizing there's alot of small details that are omitted from that show.
Another professional presentation! Well done!
Congratulations on hitting 100k dude, well deserved
Almost 100k ;) Congrats in advance! Looking forward to more videos from you.
Awesome video. Love the channel. Keep it up! 🤘
I remember it well, only a couple of weeks after the Lockerbie incident.
It's mainly known here in the UK as the Kegworth air disaster, named after the nearby village of Kegworth.
Another great video!
I agree
Congratulations on 100k!
CONGRATS ON 100K!!!
I think I thought I recently seen this one somewhere but I'll just say that ur dedication is bar none seeing that you literally charter a jet a to go out and fly the crash path PLUS a chase jet to film it!! Totally /w\METAL/w\ Bruh!!
Good report and congrats on 100k
That one drives me mad everytime I hear about it. How much time would it have taken to send a crew member to check the engines ! something so simple and yet... *shaking my head*
Sending back the cabin crew would have yielded nothing. At flight idle the engine was not showing any abnormal signs.
@@Trevor_Austin It clearly says the passengers were seeing flames from engine no. 1.
Congrats on 100K subs!
I was on the motorway on the same side of the crash. The traffic came to a stand still!
If I recall , they really hounded the pilot in the media - claiming it was his fault.
Also, A friend of mine had his girl friend, on the plane. Unfortunately she died. He still misses her 30 years later!
*99.9K!!!!* Next time I visit you’ll have hit 100K bro! There’s a website you can watch the real-time numbers, I saw someone else record it for their reaction to hitting 100,000. Congrats dude you earned it! I’ve been here since maybe 20K.
EDIT: 1h later 99.8 ➡️ 99.9
Nice Video as usual
As per usual.... yes
Analog on my cars ! And on my meters at work ! Digital doesn’t give you any kind of indication of trouble until it’s to late !
I haven’t heard of the city of Trent. Do you mean the River Trent, which passes through the East Midlands?
Awesome video man ... Loving all your contents..Congrats on reaching 99k subscribers
Thank you!
I've heard this story a hundred times, but it's still incredible to me that it happened.
Analog vs Digital. Hard to say in this case because it's a digital simulation of an analog (rotary dial) instrument which IMHO is the worst of both worlds. As a UI designer that doesn't make sense to me an what I see here is IMHO indeed confusing. Both the shapes, contrast and color scheme shout "poor design". Why not use a horizontal or vertical bar where the length is proportional to the value and the color (green, orange, red - these colors might ring a bell) indicates values that are dangerous or require attention and flashing red indicating immediate action is required.
In an emergency the actual values (with 3 decimal places precision) are not important. What matters is to be able to see in an instant if they are outside of the allowed range.
I love this channel, very interesting content. You cannot escape the fact that they shut the wrong engine down on a 2 engine aircraft! The other causes are supplementary in my view.
was working on a fictional air crash investigation (also with the 737) when this came out very epic
Coincidence... I think not
@@stewartmeetball3417 I didn't know mini air crash investigation would upload so yes, coincidence.
Analogue instruments are much easier to read and much less affected by glare. I so hate all these fancy digital displays and touch screen in my car.
This is a good channel
I heard about this one on another flight Channel. This one is particularly interesting because the passengers could see the problem and the pilots couldn't and probably assumed they had it under control.
I just got my Private Pilot license... so having one engine working, shouldn't they stay a little bit above the glide slope in case the other engine fails too? And shouldn't they be ready to turn the power on the right engine back on at any moment? Even if it's broken, when they shut it down, it was giving power although they thought the vibrations were on it.
I'm brazzilian, so I don't know how it's called in english but here we would simulate loss of power and I would always preffer to be above the glide slope in the case of a simulation being applied by the instructor.
Ps: Sorry for my bad english :/
Dual engine failure is extremely rare in commercial jets, so the pilots were probably not anticipating any problems with the remaining engine (and I think that engine was set to idle; from idle it would still take 8 or 9 seconds to spool back up). Also in a commercial jet, pilots are supposed to avoid being high on the glide slope because it is more risky with a heavy aircraft.
You cannot just start a jet engine like a Cessna 172. The engine was shut down so it would need to be started back up again and when the other engine died the only other way would be APU as the plane would not be travelling fast enough for a windmill start
Your English is considerably better than most English people's English.
Your vids are great. Really find these facinating. I live about 30 mins drive from where this accident took place. And pre covid I often flew from east Midlands airport
Excellent video. This occurred just a few weeks after the Pan Am 103 atrocity; dreadful times.
Very interesting - thank you.
Regarding the instruments and analog vs digital. It's not really that simple, because many instruments can appear to be analog (moving needles) but be actually driven by digital data. Specifically for vibration meters, though, I believe that an analog indicator is preferable. The eye is naturally drawn to motion. So a well-illuminated vibrating indicator will be noticed more easily than a number. But in either case another improvement would be for the digital logic to turn on a bright red light if the vibration exceeds a specified level - again, a change that attracts the eye.
"Human Factors" is a very important set of considerations, but too often is not adequately addressed in systems development, implementation and integration.
Sooooo close to 100K subs!!!! 😁
My dad was working ground service at Belfast when the disaster occurred. I remember him telling me about how him and his co-workers by how late the plane was until another worker came to tell them what had happened.
The engine instruments pictured are segmented LEDs and were likely made by Smith’s Industries. They also referred to them as EIDS (Engine Instrument Display System). They made a similar product for the C-130. I was working at Lockheed in the mid90s on the USCS P-3 program. They wanted to replace the analog “soup can” instruments with something a little more modern. After doing a survey and analysis of available systems I selected the EIDS as the P-3 engine and the C-130 engine were the same (T-56). There were some differences in how the C-130 and the P-3 measured power but mostly they are the same. The USCS was pleased with the system although the Flight Engineers took some time to get used to the new display.
This actually reminds me a little bit of what happened to Flying Tiger 923. While they had a ton of other stuff going wrong with the plane, they made the problem worse by feathering the wrong prop, and that's what doomed them to ditch in the North Atlantic. They did have some survivors but it still goes to show what can happen under pressure. (You can read the recent book Tiger in the Sea for the story on that crash.)
I remember flying into East Midlands either the next day or the day after - from the cockpit you could see just how close they almost made it , plus how lucky they were not to pancake onto the motorway itself. As an aside, I always preferred steam gauges to glass cockpits.
Analog for sure, though a mix is always good.
another factor in the crash i feel is that no one from the cabin told the pilots, they even told the passengers right hand engine
"Assumptions" led to this crash. From start to finish.
Love the mentourpilot mention!!
You're this close 🤏 to 10k subs! You deserve another 10k. The research, writing and narration on your videos are absolutely amazing!
This accident happened about 2 weeks after Pan Am 103/Lockerbie and the UK was still very much in shock from that, it was really unbelievable that another fatal air incident had occurred so soon. Many of the survivors of this, particularly those in the upside down tail section, took a long time to be cut free and had horrendous, life changing injuries such as amputations and paralysis. It really does make a good argument for wing/engine cameras to be installed on all planes.
I lived in Birmingham, which is about 30miles from East Midlands Airport, at the time of this incident. The scar on the bank of the motorway was there for months after the motorway reopened, a sad reminder of those who lost their lives there.
In a terrible twist of fate, British Midland was running an advertising campaign at the time with a picture of an aircraft and the title "The new fast lane to London", which was where the motorway that they crashed on, the M1 lead to, to the south.
New fast lane with a crashed plane next to an advertisement. Now that is dark
Another great video. I personally prefer digital display, but the needle should definitely be longer and more visible at a glance. In this case Boeing chose futuristic look of the design over practicality and sadly 47 people paid the price.
Did the pilots die?
I have watched so many videos on disaster flights. Two things I am convinced of : 1) there is not enough communication between the cockpit and the cabin and 2) passengers are too reluctant to bring up issues they see with the plane to avoid embarrassment. If only the passengers had pointed out that the left engine was on fire as soon as they saw it.
After watching a thousand air crash videos I have a simple question. Why are there no cameras pointed at the engines? There are so many crashes due to the pilots not knowing the condition of the engines. A few hundred dollars of hardware.
That is exactly what I was just thinking also! Like you said a few hundred dollars of hardware could save lives and companies money!!
This one was covered by Mentour Pilot 1 month ago or so, "What Caused the Kegworth Air Disaster? | British Midland flight 92".
personaly i think analog gauges (or digital with proper length needles) is the best one if you need information in a glance.
Definitely. Analog gauges are much easier to read for getting approximate information fast, but more work if you're trying to get more exact data.
I like the mention to the Mentour Pilot
This was one of the first jet crashes that involved redesigned jet airliner seats that could withstand 16 g instead of old seats which could only withstand 9 g. Most of the people that survived were able to do so thanks to those seats. Had it been fitted with the old designed seats, the death toll would have been far greater.
I remember travelling up to my Grandparents house in Rochdale about a month after the crash and you could see the blackened backing at the side of the M1 where the plane had crashed. Also the trees had been knocked over so it was like a chunk had been taken out of the banking. Very sobering sight.
Pilots must have a monitor by which they can see the engines!
Weird that people had to die because pilots don’t like the gauges. I don’t like them so Im not going to use them. :(
Right?! The arrogance of some people is immeasurable.
I think the main error was not asking flight crew to visually check which engine is smoking.
Did u throw out that old maple syrup ,
BTW as always nice videos
Crazy too think that two experienced pilots would make such mistakes
Babe wake up, new Mini Air Crash Investigation video
I think it's difficult to quantify whether one factor or another had contributed more to a crash. But it is commonly said in air traffic incident reports that a crash is a result of a long chain of failures to produce an incident. If just one factor was different, the results could potentially have turned out differently, for better or worse.
That said, since you asked me for the most significant factors: I feel the failure to certify the engines properly which directly led to the engine failure, second to that was the pilots shutting down the wrong engine and not catching the error.
So to use investigation terminology: the root cause is the inadequate engine testing/certification and the lack of pilot training to know the plane they're flying and to properly ID the failing engine, contributatory cause is the lack of CRM and failure of the cabin crew to notify the pilots that its the left engine that's exhibiting failure signs (flames and vibrations) especially after the PA that announced the problem was with right engine.
Root cause analysis is one method but its failing is that it searches out the “guilty” part. The moment you stick guilt or blame in an accident investigation the real data dries up and the wrong people’s lives get ruined. The critical part in this accident was that an engine was needlessly shut down. Not being familiar with the QRH applicable at the time or BM’s SOP’s I haven’t a clue if this was standard or not. Throttling back to flight idle eliminated the vibration and had the engine been left to run in this state nothing would have happened. So the Root Cause was the incorrect action of shutting down an engine that was not displaying any abnormal parameters.
You mean to tell us public that at the time people on the plane could see flames and knew there was a problem with the left engine, but no one told a flight crew this. ? Captain comes on inter com and tells passengers there is a problem with the right hand engine. !! But no one say's a thing about flames coming out of the left engine... Well i guess the pilot must know what he's doing then.. Best not say anything... After all we don't want to look like a right prat Eh ??
I work with analog panel meters and yes, they are easier to read without a doubt. However mechanical failures are more likely than electrical failures so they are no where near as dependable. Even a build up of static charge is enough to cause serious issues with a analog meter. I would imagine the meters use a 4-20mADC signal so your not contending with voltage drops across the conductors. Not to mention you then have an indication of if the meter is truly at zero or if it’s off.
So, not only did the pilots not ask cabin crew to check the engines, they did not themselves go back to check, nor did the cabin crew raise the matter with the pilots after hearing the announcement of problems with the right engine, nor did the passengers raise the issue with cabin crew upon seeing flames from the left engine. Amazing.
City of trent? Trent is a common river name. Do you mean stoke on trent? That'd shorten to stoke. Trent is very unhelpful. it'd be like calling London 'Thames' instead of London
Have to forgive the Yanks. Remember New York is in Canada 😂😂😂😂
Wonderful video. I think it was inadequate training on the air-conditioning system of this new version of the 737 (i.e. that the cabin air is fed by both engines), coupled with the difficulty to read the gauges when the plane is vibrating so much and the fact that, after they had shut down the wrong engine, the vibrations stopped (leading the crew to assume that they had shut down the correct engine) that together led to the crash. There was also the fact that the captain told the passengers that he had shut down the right-hand engine whilst many of these passengers could see fire coming out of the left-hand engine but failed to inform the cabin crew of this! Then, there was sheer bad luck - they came so close to landing, after all.
One correction: to the best of my knowledge, there is no city called Trent: Trent VOR is in the middle of the countryside, named after the River Trent.
Didn't you already upload this one? I distinctly remember the part where the passengers saw flames coming from the left-hand engine.
Or is there a similar but different incident that also had the pilots shutting down the wrong engine?
Someone else made a comment about this one being similar to a Transasia flight. I guess you better just have to do a complete rewatch ;-)
i’ve never been this one early for a video 🤣🤣
Either being an airline pilot shutting down the wrong engine down, or mechanics or doctors or dentists etc etc its shocking how many inept people there are. Customer service is extinct, people are rude and hateful. Ah the human race.
Analog gauges are usually more readable, but less illuminated.
One issue with digital displays, especially early ones, is vibrations can cause the image to 'jitter'. If the vibrations happen to match up with the refresh rate of the displays, they can become very blurry, especially at night.
Digital display tech is still moving forwards by leaps and bounds and this specific issue is really only noticeable on displays made in the 80s-2000s
Aviation industry is one of the pioneering forces behind LCD displays going up to and past 100hz, it didn't take very long to realize low hz displays were unreadable when the plane started vibrating.
I'm not certain what today's standards are, but I would not be surprised if avionic displays were in the 240 hz range, even if the signal was only 60FPS, just to reduce flickering.
Analog gauges, being mechanical in nature, are more prone to inaccuracy and mechanical failure. Air Force One primarily uses Analog avionics
There is no city called Trent. Trent is the name of a VOR with the indent “TNT”. East Midlands was chosen because they were familiar with it, the weather was good and it was one of their engineering bases, so it was very sensible choice.
What we have learnt from this incident is don’t shut down a “broken” engine unless you have to, let it run at flight idle. We have also changed the layout of engine instruments from LRLR to LLRR. We have also learnt more about dealing with cabin crew and improved our communications with them. Great leaps forward have been made in training as well. As an aside the principle of not shutting down engines and leaving them to run at idle has resulted in some turboprop accidents. A jet aircraft is designed to fly with an engine shut down or running at idle. A turbo-prop will produce a large amount of drag at flight idle so they have to be feathered or run at 12-15% torque to produce minimal drag. A SAAB 340 crashed at Schiphol with one engine at idle.
Indeed, the two cities closest to East Midlands airport are Nottingham and Derby. I was born and brought up in South Derbyshire and EMA was our nearest airport, I flew from there many, many times.
Also my aunt and uncle lived in Kegworth at this time and heard the crash!
In fs2020 digital gusges, I mostly fly the 320nx in fs2020
As I recall, final in this case was flown with flaps on. They'd probably want flaps on when actually touching down, but that doesn't mean flaps down for the whole final. In my limited experience, if you need distance and have no power, reduce drag immediately. And that means flaps up. Lower flaps again when the ship reaches the correct glide slope. This of course assumes they had power available to operate the flaps.
Looking at a conventional clock or watch it is not necessary to see the numbers on the dial to know what time it is. With only a digital watch you have to read the numbers.
I think they changed the 'brace' position used by U.K. airlines after this crash due to the number of lower leg injuries(?)
I saw the crash site and all the emergency services on the ground shortly after the crash as we were on the road and got diverted up over the bridge a bit further down the M1. Didn't know for sure what it was at the time but there was so many flashing lights and the location we assumed it was a plane.
Non protruding , flush finished , external CCTV monitoring cameras , with emphasis towards the jet engines , should be an enforced safety standard on all commercial airliners , especially the ones made by BOEING .
The airlines or the manufacturers of the planes need to start mounting small closed circuit cameras on each side of the planes, so the pilots can see the engines from the cockpit. It makes perfect sense to me.
I don't get why the passengers didn't draw attn to the mistake. What about the cabin crew? They could see out the windows talk with passengers... Why didn't the pilots proactively get a visual inspection? If I had some emergency. I would confirm by using the old, dependable "driver's side/passenger side." This story is heartbreaking.
As a former flight attendant, we were trained to notify the cockpit if we thought there was wrong with plane. Usually, if a person is a fearful flier, we wouldn't have blown that off. We always to reassure them. Better for them, better for us.