The Kegworth air disaster occurred when British Midland Flight 92, a Boeing 737-400, crashed on to the embankment of the M1 motorway near Kegworth, Leicestershire, England, while attempting to make an emergency landing at East Midlands Airport on 8 January 1989.
2. WHAT HAPPENED
On 8th January, 1989, British midland flight 92
crashed while undertaking an emergency
landing.
Crashed site : M1 embankment near the village
of Kegworth.
The Boeing 737-400 aircraft was severely
damaged.
79 of the of the 126 people aboard the plane
3. EVENTS OF THE CRASH
1. During the ascent of the aircraft to its cruising altitude
of 35,000 feet metal fatigue occurred on the fan blades
in the left engine.Due to the engine design not being
able to withstand vibrations caused by
operation above 25,000 feet and a
high power setting.
2. Fan blade broke off causing decrease in power and
increase in vibrations. This caused the left engine to
produce a jet of flames.
3. Smoke flooded into the cabin. Captain shut down the
engine on the right.
4. Smell of smoke and vibrations reduced.
4. CAUSES OF THE CRASH
The flight crew shut down the right engine, in
response to the left engine being damaged.
The left engine then completely failed due to
increased stress during approach to land.
The wrong engine was shut down.
Primary cause: Human error
Secondary cause: Technical failure
5. INADEQUATE KNOWLEDGE OF THE AIRCRAFT
Flight crew observed smoke in the cabin.
Believed they could not trust the Vibration
sensors. Was true because of the old Boeing
737 but not the new 737-400.
Fell back on general knowledge of aircraft
which was wrong.
Thought that bleed air (pressure and heating)
was taken from the right engine.
In fact the air conditioning systems utilized both
7. INADEQUATE TRAINING
The combination of violent engine vibrations
and the smell of smoke while climbing to
covered attitude was not covered in training.
Two separate protocols existed for each
event but not in conjunction.
No simulation training for engine failure of
this kind, or what to do if the situations fall
out of bounds of standard procedures.
Differences in the Boeing 737 and 737-400
were not adequately taught.
8. WHY THE MISTAKE WAS NOT FOUND
By chance the smoke dissipated and the
vibrations reduced – this was actually due to
standard procedure reducing fuel flow to both
the engines.
Pilots did not communicate with the cabin crew
who had visual confirmation of which engine
was damaged.
Immediate division to Midlands airport create a
high cabin workload this resulted in incorrect
review procedure after the right engine was
shut down.
11. REFERENCES
Air Accidents Investigation Branch. (2012). June 2012 Bulletin. Aldershot: Air
Accidents Investigation Branch.
Air Accidents Investigation Branch. (1989). Report on the Accident to Boeing 737-
400 G-OBME near Kegworth, Leicesterhire on 8 Janury 1989. Aldershot: Air
Accidents Investigation Branch.
Smith, D. (2000). On a wing and a prayer? Exploring the human components of
technological failure.
Youtube.