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KEGWORTH AIR
DISASTER
presented by
Abdussamad Abid
Noor Hussain
Hassan Saleem
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
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.
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
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
BOEING 737-400
(NEW)
BOEING 737 (OLD)
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.
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.
BRITISH MIDLAND FLIGHT 92
CRASH ANIMATION
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.
Kegworth Air Disaster

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Kegworth Air Disaster

  • 1. KEGWORTH AIR DISASTER presented by Abdussamad Abid Noor Hussain Hassan Saleem
  • 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.
  • 9.
  • 10. BRITISH MIDLAND FLIGHT 92 CRASH ANIMATION
  • 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.