Event Details


Title:Crash short of runway, Boeing 737-400, British Midlands, G-OBME at Nottingham East Midlands Airport (Recommended)
Micro summary:This Boeing 737-400 crashed short of the runway following an engine failure and incorrect shutdown of the good engine.
Event Time:1989-01-08 at 2025 UTC
File Name:1989-01-08-UK.pdf
Publishing Agency:Aircraft Accident Investigation Board (AAIB)
Publishing Country:United Kingdom
Report number:EW/C1095
Pages:121
Site of event:1/2 nm east of East Midlands AIrport
Latitude/Longitude:5249'54"N 00120'54"W
Departure:London Heathrow Airport, London, England, United Kingdom
Destination:Belfast
Airplane Type(s):Boeing 737-400
Flight Phase:Landing
Registration(s):G-OBME
Operator(s):BMI British Midland Airways
Type of flight:Revenue
Occupants:126
Fatalities:47
Serious Injuries:74
Minor/Non-Injured:5
Other Injuries:0
Executive Summary:G-OBME left Heathrow Airport for Belfast at 1952 hrs with 8 crew and 118 passengers (including 1 infant) 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. Efforts to restart the No 2 engine were not successful.

The aircraft initially struck a field adjacent to the eastern embankment of the M1 motorway and then suffered a second severe impact on the sloping western embankment of the motorway. 39 passengers died in the accident and a further 8 passengers died later from their injuries. Of the other 79 occupants, 74 suffered serious injury.

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 a major thrust loss due to secondary fan damage after power had been increased during the final approach to land.

The following factors contributed to the incorrect response of the flight crew:

1. The combination of heavy engine vibration, noise, shuddering and an associated smell of fire were outside their training and experience.

2. They reacted to the initial engine problem prematurely and in a way that was contrary to their training.

3. They did not assimilate the indications on the engine instrument display before they throttled back the No. 2 engine.

4. 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.
Learning Keywords:Operations - Cabin or Cockpit Smoke
Operations - Training Deficiency
Systems - Engine - Compressor surge/stall
Systems - Engine - Contained Engine Failure
Other - Post-Crash Survivability
Consequence - Hull Loss

 




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