Crash of a Boeing 747-237B in New Delhi

Date & Time: May 7, 1990 at 0917 LT
Type of aircraft:
Operator:
Registration:
VT-EBO
Survivors:
Yes
Schedule:
London - New Delhi - Bombay
MSN:
20558
YOM:
1972
Flight number:
AI132
Country:
Region:
Crew on board:
20
Crew fatalities:
Pax on board:
195
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
8026
Circumstances:
After touchdown at New Delhi-Indira Gandhi Airport following an uneventful flight from London-Heathrow Airport, the crew started the braking procedure and activated the thrust reversers when the pylon of the engine n°1 failed. The engine partially detached, causing a fuel line to rupture and the fuel to ignite. The aircraft was stopped after a course of almost 3 km and all 215 occupants were evacuated safely. The fire was extinguished but the aircraft was damaged beyond repair.
Probable cause:
The accident was caused due to the migration of the improperly installed diagonal-brace aft fuse-pin of the No.1 engine from its fitting which substantially reduced the load carrying capability of the engine fittings resulting in failure of the upper-link forward fuse pin due to excessive loads on account of probably improper landing leading to a partial separation of engine and fire.

Crash of a Boeing 737-4Y0 in East Midlands: 47 killed

Date & Time: Jan 8, 1989 at 2025 LT
Type of aircraft:
Operator:
Registration:
G-OBME
Survivors:
Yes
Schedule:
London - Belfast
MSN:
23867
YOM:
1988
Flight number:
BD092
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
118
Pax fatalities:
Other fatalities:
Total fatalities:
47
Captain / Total flying hours:
13176
Captain / Total hours on type:
763.00
Copilot / Total flying hours:
3290
Copilot / Total hours on type:
192
Aircraft flight hours:
521
Circumstances:
British Midland Airways Flight BD092 took off from London-Heathrow Airport at 1952LT on a flight to Belfast, Northern Ireland. Some 13 minutes later, while climbing through FL283, moderate to severe vibration was felt, accompanied by a smell of fire in the cockpit. The outer panel of one of the n°1 engine fan blades detached, causing compressor stalls and airframe shuddering. Believing the n°2 engine had been damaged the crew throttled it back. The shuddering stopped and the n°2 engine was shut down. The crew then decided to divert to East Midlands Airport. The flight was cleared for an approach to runway 27. At 900 feet, 2.4 nm from the runway threshold, the n°1 engine power suddenly suffered a decrease in power. As the speed fell below 125 knots, the stick shaker activated and the aircraft struck trees at a speed of 115 knots. The aircraft continued and impacted the western carriageway of the M1 motorway 10 meters lower and came to rest against a wooded embankment, 1'023 meters short of runway threshold. 47 passengers were killed while all other occupants were injured, some of them seriously.
Probable cause:
The operating crew shut down the n°2 engine after a fan blade had fractured in the n°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 n°2 engine;
4. As the n°2 engine was throttled back, the noise and shuddering associated with the surging of the n°1 engine ceased, persuading them that they had correctly identified the defective engine;
5. They were not informed of the flames which had emanated from the n°1 engine and which had been observed by many on board, including 3 cabin attendants in the aft cabin.
Final Report:

Crash of a Boeing 747-121A in Lockerbie: 270 killed

Date & Time: Dec 21, 1988 at 1903 LT
Type of aircraft:
Operator:
Registration:
N739PA
Flight Phase:
Survivors:
No
Site:
Schedule:
London - New York
MSN:
19646
YOM:
1970
Flight number:
PA103
Region:
Crew on board:
16
Crew fatalities:
Pax on board:
243
Pax fatalities:
Other fatalities:
Total fatalities:
270
Captain / Total flying hours:
10910
Captain / Total hours on type:
4107.00
Copilot / Total flying hours:
11855
Copilot / Total hours on type:
5517
Aircraft flight hours:
72464
Aircraft flight cycles:
16497
Circumstances:
Flight PA103 departed London-Heathrow runway 27R for New York at 18:25. The aircraft levelled off at FL310, 31 minutes later. At 19:03 Shanwick Oceanic Control transmitted an oceanic clearance. At that time an explosion occurred in the aircraft's forward cargo hold at position 4L. The explosive forces produced a large hole in the fuselage structure and disrupted the main cabin floor. Major cracks continued to propagate from the large hole while containers and items of cargo ejected through the hole, striking the empennage, left- and right tail plane. The forward fuselage and flight deck area separated when the aircraft was in a nose down and left roll attitude, peeling away to the right at Station 800. The nose section then knocked the no. 3 engine off its pylon. The remaining aircraft disintegrated while it was descending nearly vertically from 19000 feet to 9000 feet. A section of cabin floor and baggage hold (from approx. Station 1241-1920) fell onto housing at Rosebank Terrace, Lockerbie. The main wing structure struck the ground with a high yaw angle at Sherwood Crescent, Lockerbie causing a massive fire. The Semtex bomb which caused the explosion had probably been hidden in a radio cassette player and was transferred to PA103 from a Pan Am Boeing 727 flight, arriving from Frankfurt. After a three-year joint investigation by the Dumfries and Galloway Constabulary and the U.S. Federal Bureau of Investigation indictments for murder were issued on November 13, 1991, against Abdel Basset Ali al-Megrahi, a Libyan intelligence officer and the head of security for Libyan Arab Airlines (LAA), and Lamin Khalifah Fhimah, the LAA station manager in Luqa Airport, Malta. United Nations sanctions against Libya and protracted negotiations with the Libyan leader Colonel Muammar al-Gaddafi secured the handover of the accused on April 5, 1999. On January 31, 2001, Megrahi was convicted of murder by a panel of three Scottish judges, and sentenced to 27 years in prison. Fhimah was acquitted.
Probable cause:
The in-flight disintegration of the aircraft was caused by the detonation of an improvised explosive device located in a baggage container positioned on the left side of the forward cargo hold at aircraft station 700.
Final Report:

Crash of a Boeing 747-237B in the Atlantic Ocean: 329 killed

Date & Time: Jun 23, 1985 at 0715 LT
Type of aircraft:
Operator:
Registration:
VT-EFO
Flight Phase:
Survivors:
No
Schedule:
Vancouver – Toronto – Montreal – London – New Delhi – Bombay
MSN:
21473
YOM:
1978
Flight number:
AI182
Country:
Region:
Crew on board:
22
Crew fatalities:
Pax on board:
307
Pax fatalities:
Other fatalities:
Total fatalities:
329
Captain / Total flying hours:
20379
Captain / Total hours on type:
6488.00
Copilot / Total flying hours:
7489
Copilot / Total hours on type:
2469
Aircraft flight hours:
23634
Aircraft flight cycles:
7525
Circumstances:
On the morning of 23rd June, 1985 Air India's Boeing 747 aircraft VT-EFO (Kanishka) was on a scheduled passenger flight (AI182) from Montreal and was proceeding to London enroute to Delhi and Bombay. It was being monitored at Shannon on the radar scope. At about 0714 GMT it suddenly disappeared from the radar scope and the aircraft, which had been flying at an altitude of approximately 31,000 feet, plunged into the Atlantic Ocean off the southwest coast of Ireland at position latitude 51° 3.6' N and longitude 12° 49' W. This was one of the worst air disasters wherein all the 307 passengers plus 22 crew members perished. The fact that emergency had arisen was first by Shannon Upper Area Control (UAC) after the aircraft had disappeared from the radar scope. The control gave a number of calls to the aircraft but there was obviously no response. Thereafter various messages were transmitted and that is how the rest of the world came to know of the accident. Shannon Control at 0730 hours advised the Marine Rescue Coordination Center (MRCC) about the situation which appeared to have arisen. MRCC, in turn, explained the situation to Valencia Coast Station and requested for a Pan Broadcast. Thereafter ships started converging on the scene of the accident and they commenced search and rescue operations.
Probable cause:
The following findings were reported:
- The aircraft was subjected to a sudden event at an altitude of 31,000 feet resulting in its crash into the sea and the death of all on board,
- The forward and aft cargo compartments ruptured before water impact,
- The section aft of the wings of the aircraft separated from the forward portion before water impact.
- There is no evidence to indicate that structural failure of the aircraft was the lead event in this occurrence.
- There is considerable circumstantial and other evidence to indicate that the initial event was an explosion occurring in the forward cargo compartment. This evidence is not conclusive. However, the evidence does not support any other conclusion.
Final Report:

Crash of a Hawker Siddeley HS.121 Trident 3B in Vrbovec: 63 killed

Date & Time: Sep 10, 1976 at 1114 LT
Operator:
Registration:
G-AWZT
Flight Phase:
Survivors:
No
Schedule:
London - Istanbul
MSN:
2320
YOM:
1972
Flight number:
BA476
Country:
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
54
Pax fatalities:
Other fatalities:
Total fatalities:
63
Captain / Total flying hours:
10781
Captain / Total hours on type:
399.00
Copilot / Total flying hours:
3655
Copilot / Total hours on type:
1592
Aircraft flight hours:
8627
Aircraft flight cycles:
6952
Circumstances:
Hawker Siddeley HS-121 Trident 3B operated by British Airways as flight BE476 and a McDonnell Douglas DC-9-32, operated by Inex-Adria Aviopromet, were destroyed when both aircraft crashed near Vrobec following a mid-air collision. All 176 on board both aircraft were killed. The Trident was on a scheduled flight from London-Heathrow Airport in England to Istanbul-Yesilköy Airport in Turkey, carrying 54 passengers and a crew of 9. The aircraft took off at 08:32 GMT and the flight proceeded normally. First contact with the Zagreb Area Control Centre was established on the Upper Sector frequency 134,45 MHz at 10:04 GMT. The flight was requested to report passing the Zagreb VOR at flight level 330. The aircraft flew along the centreline of airway UB5 with slight side deviation 1-2 km to the right due to wind. At 2 minutes and 50 seconds before the collision, the aircraft changed heading to 115° to head back towards the airway centreline. Airspeed was 295 Kts. The DC-9 departed Split Airport at 09:48 GMT to fly 108 West German tourists back to Cologne. Flight JP550 was issued instructions to climb to FL180. At 09:54 the flight, on passing flight level 130, switched to the Zagreb Area Control Centre lower sector east frequency of 124.6 MHz, receiving clearance to climb to FL240 and later to FL260. At 10:03 the crew switched to the frequency of the middle sector controller, responsible for safety and regulation of traffic between flight levels 250 and 310. This controller cleared to flight to FL350. The aircraft assumed a heading of 353° and a speed of 273 Kts as it passed a beam and to the west of the KOS NDB, approximately 2-3 km from the airway centreline. While heading towards the Zagreb VOR, the flight crew radioed the Upper Sector controller on frequency 134,45 MHz at 10:14:04 GMT and reported that they were climbing through FL325. The controller then requested, in Serbo-Croatian, flight JP550 to maintain their present altitude and report passing the Zagreb VOR. The controller stated that an aircraft was in front passing from left to right at FL335, while in fact BE476 was at FL330. At 10:14:38 the crew replied, also in Serbo-Croatian, that they where maintaining FL330. Three seconds later both aircraft collided. The outer five meters of the DC-9's left wing cut through the Trident's cockpit. Due to the sudden decompression, the forward part of the Trident's fuselage disintegrated. The remaining part of the fuselage struck the ground tail-first. With it's left wing torn off, the DC-9 tumbled down and hit the ground right-wing first.
Probable cause:
Direct cause of the accident was the struck of the DC-9 wing into the middle side of the Trident 3B fuselage which occurred at the height of 33.000 feet above Zagreb VOR so that both aircraft became uncontrollable and fell on the ground.
- Improper ATC operation,
- Non-compliance with regulations on continuous listening to the appropriate radio frequency of ATC,
- Non-performance of look-out duty from the cockpits of either aircraft.
Final Report:

Crash of a Hawker-Siddeley HS.121 Trident 1E-140 in Bilbao

Date & Time: Sep 15, 1975 at 1548 LT
Operator:
Registration:
G-AVYD
Flight Phase:
Survivors:
Yes
Schedule:
Bilbao - London
MSN:
2138
YOM:
1969
Flight number:
BA552
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
110
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
10895
Captain / Total hours on type:
1685.00
Copilot / Total flying hours:
5359
Copilot / Total hours on type:
782
Aircraft flight hours:
12892
Circumstances:
The taxi drills were actioned by the First Officer and the Flight Engineer during this time and "runway items" were completed after the Commander turned the aircraft through 180° close to the threshold of runway 28, aligned it on the runway centre line, and selected the wheel brakes to park. A power setting of 100 per cent thrust was made, all engine indications were checked as correct, and the engine relight switches were selected 'ON' before the wheel brakes were released and the takeoff run commenced at about 13:46 with the Commander piloting the aircraft. The aircraft accelerated normally ; the First Officer called out the indicated airspeeds at 80 knots and 100 knots and made a call of 'Wet V1' at 117 knots then removed his hand from the throttles. At the time or just after 'Wet V1' was called the Flight Engineer and the First Officer heard a noise which the latter crew member attributed to the aircraft's entry into standing water. According to the Flight Engineer the aircraft appeared to decelerate at the same time that he heard the noise. The Commander felt a marked deceleration consistent with a loss of engine power, whereupon he immediately closed the throttles, called "Abandon", deployed the airbrakes and lift dumpers and applied the wheel brakes fully. However according to the Flight Engineer all engine indications had been normal prior to the closing of the throttles. On seeing a hand close the throttles the First Officer selected emergency reverse thrust on the pod engines, checked the engine indications were correct and maintained the application of emergency reverse thrust until the aircraft eventually came to rest. The First Officer and the Commander checked the indicated pressures on the wheel brake gauges which showed the wheel brakes were fully applied. The initial deceleration felt satisfactory to the crew, then quickly deteriorated and the First Officer formed the impression that the aircraft was aquaplaning. The Flight Engineer then noticed that the aircraft had begun to drift gradually to the left of the runway centreline apparently as the result of a deliberate action by the Commander. Subsequently it became evident to the Commander that he could not bring the aircraft to a halt within the runway confines. Some 200 metres to 300 metres before the end of the runway he turned the aircraft to the left using nose-wheel steering and applied full left rudder. As the nose wheels ran off the runway onto the grass, the aircraft slewed to the left then skidded broadside to the right for a short distance before it came to an abrupt stop at the side of the runway in a right wing down attitude with the right wing tip close to the threshold lights of runway 10. Evacuation drills were initiated and the passengers left the aircraft in a reasonably orderly manner, the majority by slide from the main exit doors and foremost right overwing emergency exit. Catering equipment in the galleys came out of stowage during the accident obstructing access to the forward emergency exit door and preventing use of this exit and its slide during the evacuation. All 117 occupants escaped uninjured while the aircraft was considered as damaged beyond repair.
Probable cause:
The accident was caused by the Commander's decision to abandon take-off on a wet runway at or close to V 1 . Contributory factors were the low effective braking coefficient of friction achieved by the aircraft and the failure of the Commander to ascertain the extent and depth of water present on the runway prior to takeoff.
Final Report:

Crash of a Douglas DC-10-10 in Ermenonville: 346 killed

Date & Time: Mar 3, 1974 at 1141 LT
Type of aircraft:
Operator:
Registration:
TC-JAV
Flight Phase:
Survivors:
No
Schedule:
Ankara - Paris - London
MSN:
46704
YOM:
1972
Flight number:
TK981
Country:
Region:
Crew on board:
12
Crew fatalities:
Pax on board:
334
Pax fatalities:
Other fatalities:
Total fatalities:
346
Captain / Total flying hours:
7003
Captain / Total hours on type:
438.00
Copilot / Total flying hours:
5589
Copilot / Total hours on type:
628
Aircraft flight hours:
2955
Circumstances:
On Sunday March 3, 1974 flight TK981 departed Istanbul for a flight to Paris and London. The DC-10 landed at Paris-Orly at 11:02 and taxied to stand A2. There were 167 passengers on board, of whom 50 disembarked. The aircraft was refueled and baggage was loaded onto the plane. The planned turnaround time of one hour was delayed by 30 minutes. An additional 216 passengers embarked. Most of the passengers were booked on this flight because of a strike at British Airways. The door of the aft cargo compartment on the left-hand side was closed at about 11:35. When all preparations were complete the flight received permission to taxi to runway 08 at 12:24. Four minutes later the crew were cleared to line up for departure and were cleared for departure route 181 and an initial climb to flight level 40. The aircraft took off at approximately 12:30 and was cleared by Orly Departure to climb to FL60, which was reached at 12:34. The North Area Control Centre then cleared TK981 further to FL230. Three or four seconds before 12:40:00 hours, the noise of decompression was heard and the co-pilot said: "the fuselage has burst" and the pressurization aural warning sounded. This was caused by the opening and separation of the aft left-hand cargo door. The pressure difference in the cargo bay and passenger cabin, the floor above the cargo door partly collapsed. Two occupied tripe seat units were ejected from the aircraft. All the horizontal stabilizer and elevator control cables routed beneath the floor of the DC-10 and were thus also severely disrupted. Also the no. 2 engine power was lost almost completely. The aircraft turned 9 deg to the left and pitched nose down. The nose-down attitude increased rapidly to -20 deg. Although the no. 1 and 3 engines were throttled back the speed increased to 360 kts. The pitch attitude then progressively increased to -4 degrees and the speed became steady at 430 kts (800 km/h). At a left bank of 17 degrees the DC-10 crashed into the forest of Ermenonville, 37 km NE of Paris. The aircraft disintegrated on impact and all 346 occupants were killed, among them 48 Japanese citizens and almost 250 British people.
Probable cause:
The accident was the result of the ejection in flight of the aft cargo door on the left-hand side: the sudden depressurization which followed led to the disruption of the floor structure, causing six passengers and parts of the aircraft to be ejected, rendering No.2 engine inoperative and impairing the flight controls (tail surfaces) so that it was impossible for the crew to regain control of the aircraft. The underlying factor in the sequence of events leading to the accident was the incorrect engagement of the door latching mechanism before take-off. The characteristics of the design of the mechanism made it possible for the vent door to be apparently closed and the cargo door apparently locked when in fact the latches were not fully closed and the lock pins were not in place. It should be noted, however that a view port was provided so that there could be a visual check of the engagement of the lock pins. This defective closing of the door resulted from a combination of various factors:
- Incomplete application of Service Bulletin 52-37;
- Incorrect modifications and adjustments which led, in particular, to insufficient protrusion of the lock pins and to the switching off of the flight deck visual warning light before the door was locked;
- The circumstances of the closure of the door during the stop at Orly, and, in particular, the absence of any visual inspection, through the viewport to verify that the lock pins were effectively engaged, although at the time of the accident inspection was rendered difficult by the inadequate diameter of the view port.
Finally, although there was apparent redundancy of the flight control systems, the fact that the pressure relief vents between the cargo compartment and the passenger cabin were inadequate and that all the flight control cables were routed beneath the floor placed the aircraft in grave danger in the case of any sudden depressurization causing substantial damage to that part of the structure. All these risks had already become evident, nineteen months earlier, at the time of the Windsor accident, but no efficacious corrective action had followed.
Final Report:

Crash of a Douglas DC-9-32 in La Planche: 68 killed

Date & Time: Mar 5, 1973 at 1352 LT
Type of aircraft:
Operator:
Registration:
EC-BII
Flight Phase:
Survivors:
No
Schedule:
Palma de Majorca - London
MSN:
47077/148
YOM:
1967
Flight number:
IB504
Country:
Region:
Crew on board:
7
Crew fatalities:
Pax on board:
61
Pax fatalities:
Other fatalities:
Total fatalities:
68
Captain / Total flying hours:
6612
Captain / Total hours on type:
823.00
Copilot / Total flying hours:
3378
Copilot / Total hours on type:
2278
Aircraft flight hours:
10852
Aircraft flight cycles:
9452
Circumstances:
Iberia Flight 504, a DC-9, departed Palma de Majorca at 11:24 for a flight to London. At 12:19 the crew contacted Marina Control and reported at FL310, estimating at Nantes VOR at 12:52. At 12:36 the crew were told to contact Menhir Control and descend to FL290. At the same time a Spantax Convair CV-990, flight BX400 heading for London, was flying towards the Nantes VOR on the same altitude, but on a different airway. Because of this, the Convair crew were instructed arrive at the VOR at 13:00. Because the Convair was already quite close to the VOR the crew asked for confirmation of these instructions. At 12:40 the controller told them to 'Stand by' and replied two minutes later. Because the aircraft was at the ATC sector boundary the crew could barely hear the Marina controller who instructed them to contact Menhir control. The pilot erroneously thought he had to contact Menhir control when passing the Nantes VOR. In order to delay their arrival at the VOR the Spantax crew twice tried to request permission to carry out a 360-degree turn. When they did not get any answer from Marina, they initiated the turn without clearance. While in the midst of an overcast, the Convair collided with the DC-9. The CV-990 lost an outboard portion of its left wing and managed to carry out an emergency landing at Cognac-Châteaubernard Air Base (CNG). The DC-9 lost control and crashed. The air traffic control system had been taken over that day by military personnel because of a strike of the civilian controllers. The wreckage of the DC-9 was found in La Planche, about 25 km southeast of Nantes. All 68 occupants have been killed.
Probable cause:
The Clement Marot Plan, the military contingency system to replace the civil air traffic services units in the event of a strike, by the very reason of its exceptional nature implied the use of rigorous planning traffic limitation per sector on the basis of control capacity and particularly strict compliance with the special regulations of the RAC-7 plan. The assignment of the same flight level by the control to the two aircraft IB 504 and BX 400, due to arrive at Nantes at the same time, created a source of conflict. The solution chosen by Menhir to resolve the conflict was based on separation in time. This solution, because of the reduction in normal separation, necessitated either particularly precise navigation by the crew of BX 400 or complete radar coverage and, in both cases, trouble-free communication facilities, conditions which were not realized. The continuing progress of the flight was affected by delays attributable in part to the control, in part to the crew and also to difficulty in air/ground radio communications resulting in complete failure of the crew and the control to understand one another. At the critical juncture, the crew, unmindful of their exact position, commenced a turn in order to lose time, without having been able to obtain the agreement of the control, as a result of which the aircraft interesected the adjacent route. The unidentified aircraft whose return appeared on the radar scope of one of the Menhir sub-sectors was' not identified by Menhir control as BX 400.
Final Report:

Crash of a Hawker-Siddeley HS.121 Trident 1C in London: 118 killed

Date & Time: Jun 18, 1972 at 1711 LT
Operator:
Registration:
G-ARPI
Flight Phase:
Survivors:
No
Schedule:
London - Brussels
MSN:
2109
YOM:
1964
Flight number:
BE548
Region:
Crew on board:
9
Crew fatalities:
Pax on board:
109
Pax fatalities:
Other fatalities:
Total fatalities:
118
Captain / Total flying hours:
15000
Captain / Total hours on type:
4000.00
Copilot / Total flying hours:
1400
Copilot / Total hours on type:
750
Circumstances:
Following a normal takeoff roll on runway 28R, the aircraft rotated 42 seconds after brakes were released and lifted off 2 seconds later at 145 knots IAS. At 63 seconds the autopilot was engaged 355 feet above the runway at 170 knots IAS; the IAS speed lock was selected shortly thereafter. At 74 seconds the aircraft started a 20° banked turn to port towards the Epsom Non-Directional Beacon (NDB). At 83 seconds the captain reported 'Climbing as cleared'. He was then instructed to change frequency and contact London Air Traffic Control Centre. At 93 seconds the noise-abatement procedure was initiated. On the assumption that the captain was the handling pilot, this would involve the second officer selecting the flaps fully up and operating the thrust levers to reduce power to the pre-calculated figure. At 100 seconds the captain called 'Passing 1500' and at 103 seconds the aircraft was cleared to climb to Flight Level 60. This message was acknowledged by the captain at 108 seconds with the terse call 'up to 60'. This was the last message received from the flight. At second 114 when the airspeed was 162 knots and the altitude 1,772 feet, the droop lever was selected up putting the aircraft into the area of the stall as the droop started to move. At second 116 the stick-pusher stall recovery device operated, causing the autopilot automatically to disengage and the nose of the aircraft to pitch down and the stick-push to cease as the incidence decreased. Since the elevator trim would stay at its position on autopilot disengagement which at that speed with the droop up would be - the incidence then increased causing a second stick-push at second 124 and a third at second 127. At second 128 the stall recovery system was manually inhibited by pulling the lever. The aircraft then pitched up rapidly, losing speed and height, entering very soon afterwards the true aerodynamic stall and then a deep stall from which at that height no recovery was possible. Impact was at second 150 in a field next to the A30 motorway. The aircraft was totally destroyed and none of the 118 occupants survived the crash.
Probable cause:
The immediate causes of the accident were these:
- A failure by Captain Key to achieve and maintain adequate speed after noise-abatement procedures,
- Retraction of the droops at some 60 knots below the proper speed causing the aircraft to enter the stall regime and the stick-shaker and pusher to operate,
- Failure by the crew to monitor the speed errors and to observe the movement of the droop lever,
- Failure by the crew to diagnose the reason for the stick-shaker operation and the concomitant warnings,
- The dumping by the crew of the stall recovery system.
The underlying causes were these:
- The abnormal heart condition of Captain Key leading to lack of concentration and impaired judgment sufficient to account for his toleration of the speed errors and to his retraction of, or order to retract, the droops in mistake for the flaps,
- Some distraction, the nature of which is uncertain, possibly due to the presence of Captain Collins as a passenger on the flight deck, which caused S/O Ticehurst's attention to wander from his monitoring duties,
- Lack of training directed at the possibility of 'subtle' pilot incapacitation,
- Lack of experience of S/O Keighley,
- Lack of knowledge in the crew of the possibility or implication of a change of configuration stall,
- Lack of knowledge on the part of the crew that a stick-shaker and push might be experienced almost simultaneously and of the probable cause of such an event,
- Lack of any mechanism to prevent retraction of the droops at too low a speed after flap-retraction.
Final Report: