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B734, vicinity East Midlands UK, 1989 (HF LOC FIRE AW)
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| Summary | |
| On 8 January 1989, a British Midland Airways Boeing 737-400, suffered a loss of control followed by terrain impact in the vicinity of East Midlands Airport, UK, on final approach, after an earlier engine malfunction had been followed by the shut down of the wrong engine. | |
 | |
| Event Details | |
|---|---|
| When | January 1989 |
| Event Type | AW, FIRE, HF, LOC |
| Day/Night | Night |
| Flight Conditions | IMC |
| Flight Details | |
|---|---|
| Aircraft | BOEING 737-400 |
| Operator | British Midland |
| Domicile | United Kingdom |
| Type of Flight | Public Transport (Passenger) |
| Origin | London Heathrow |
| Intended Destination | Belfast |
| Actual Destination | East Midlands |
| Flight Phase | Manoeuvring |
| MNV | |
| Location - Airport | |
|---|---|
| Airport vicinity | East Midlands |
| FIRE | |
|---|---|
| Tag(s) | Fire-Power Plant origin |
| HF | |
|---|---|
| Tag(s) | Ineffective Monitoring Procedural non compliance Inappropriate crew response (technical fault) |
| CS | |
|---|---|
| Tag(s) | Cabin air contamination |
| AW | |
|---|---|
| System(s) | Rotors Engine Fuel and Control |
| Safety Net Mitigations | |
|---|---|
| Malfunction of Relevant Safety Net | No |
| GPWS | Available but ineffective |
| Stall Protection | Available but ineffective |
| Outcome | |
|---|---|
| Damage or injury | Yes |
| Aircraft damage | Hull loss |
| Non-aircraft damage | Yes |
| Injuries | Most or all occupants |
| Fatalities | Many occupants |
| Causal Factor Group(s) | |
|---|---|
| Group(s) | Aircraft Operation Aircraft Technical |
| Safety Recommendation(s) | |
|---|---|
| Group(s) | Aircraft Operation Aircraft Airworthiness |
| Investigation Type | |
|---|---|
| Type | Independent |
Contents |
Description
On 8 January 1989, a British Midland Airways Boeing 737-400, suffered a loss of control followed by terrain impact in the vicinity of East Midlands Airport, UK, on final approach, after an earlier engine malfunction had been followed by the shut down of the wrong engine.
Synopsis
This is an extract from the official report into the accident published by the Air Accident Investigation Branch (AAIB) UK:
The aircraft “[…] left Heathrow Airport for Belfast at 1952 hrs with 8 crew and 118 passengers […] onboard. As the aircraft was climbing through 28,300 feet the outer panel 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 1 engine, which resulted in airframe shuddering, ingress of smoke and fumes to the flight deck and fluctuations of the No 1 engine parameters. Believing that the No 2 engine had suffered damage, the crew throttled that engine back and subsequently shut it down. The shuddering caused by the surging of the No 1 engine ceased as soon as the No 2 engine was throttled back, which persuaded the crew that they had dealt correctly with the emergency. They then shut down the No 2 engine. The No l engine operated apparently normally after the initial period of severe vibration and during the subsequent descent.
The crew initiated a diversion to East Midlands Airport and received radar direction from air traffic control to position the aircraft for an instrument approach to land on runway 27.
The approach continued normally, although with a high level of vibration from the No 1 engine, until an abrupt reduction of power, followed by a fire warning, occurred on this engine at a point 2.4 nm from the runway.
[…]The commander called immediately for the first officer to relight (ie restart) the other [No .2] engine and the first officer attempted to comply. The commander then raised the nose of the aircraft in an effort to reach the runway.
[…]The last airspeed recorded on the FDR was 115 kts212.98 km/h
59.11 m/s. No power became available from the No 2 engine before the aircraft struck the ground”.
The Cause of the accident was given as:
“The cause of the accident was that the operating crew shut down the No.2 engine after a fan blade had fractured in the No.1 engine. This engine subsequently suffered major thrust loss due to secondary fan damage as power was increased during the final approach to land.”
The Report identifies the following contributory factors to the incorrect response of the flight crew:
- The combination of heavy engine vibration, noise, shuddering and an associated smell of fire were outside their training and experience.
- They reacted to the initial engine problem prematurely and in a way that was contrary to their training.
- They did not assimilate the indications on the engine instrument display before they throttled back the No. 2 engine.
- As the No 2 engine was throttled 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.
- They were not informed of the flames which had emanated from the No.1 engine and which had been observed by many on board, including 3 cabin attendants in the aft cabin.
The Report's recommendations, beginning on page 118, also address institutional, manufacturers and organisational issues (see Further Reading).
Related Articles
- LOC - Loss of Control;
- FIRE - Engine Fire Protection, In-Flight Fire: Guidance for Flight Crews, In-Flight Fire: Guidance for Controllers;
Further Reading
For further information see the full accident report and appendices published by AAIB.