British Midlands Flight 92

Boeing 737-400, updated from 737-300, changes are (relevant ones to the crash):

1. More powerful engine, changing the components and fan, it was recertified as well.
2. Air condition system had also changed, at the old variant left engine bleed air fed the cockpit
primarily, but on the later one both engines feed both cockpit and cabin.
3. Engine instrumentation, the old variant had conventional gauges whereas the new variant
had LED lighting for the dials and numbers inside the dial.

At 28.300 feet, the vibrations start and a smoke that smells like burnt rubber, oil and metal comes
into the cockpit, captain thinks that the smell comes from the cabin and that is why he attributes
this to the number 2 engine (which is the engine feeds primarily the cabin in the old variant), but
he doesn’t decide yet and asks first officer which engine it is, F/O looks at the gauges, gets confused
and hesitantly says that it is right engine. Then they decide to shut off the right engine and this
decision process takes 20 seconds.

After that captain asked purser about the smoke, she said they were also experiencing smoke in the
cabin. When captain made PA, he mentioned right engine problem in it and passengers who saw the
bursts of fire coming out of the left engine got confused but never brought it up to the cabin crew,
neither the cabin crew who saw the sparks gave attention to the PA.

Captain later on reevaluates the situation, but that was interrupted by ATC and they haven’t
discussed it again.
On the approach, they leveled-off at 3000 feet, that required more thrust, so they spooled up the left
engine, when they did that, vibrations started again and at 900 feet left engine stopped working,
captain realized his mistake and told F/O to restart the engine number 2, at the same time he was
pitching up the aircraft in an attempt to stretch the glide. 19 seconds later, engine 1 fire warning
started, captain told F/O to not extinguish it since he needed any amount of thrust. Captain called to
the cabin to prepare for a crash landing, the stick shaker started and lasted until the crash, aircraft
impacted on the motorway, 1 km short of runway 27, A/C impacted the tail first and landing gears
sheered of after that, aircraft bounced and then second impact happened, it broke into 3 pieces, out
of 180 passengers and 8 crew members, 47 passengers perished.

CRM OUTCOMES:
The crew made a rushed decision in terms of shutting down the engine, the decision process was
poor.
Reducing the throttle on the faulty engine as they shut down the working engine confused them
and affected their decision process. Because when the thrust was reduced on the faulty engine
vibrations have stopped and they attributed this to shutting down of the other. They could’ve
isolated both engines and try giving them different amounts of thrust to see what causes the
problem when they had the altitude and speed to see that.
Also, the smell that came mostly from cabin made them think that it was the right engine, which is
not the case with this variant of the aircraft. He doesn’t decide by that solely, which is good. Also,
Crew’s experience with the older aircraft (L1011, DC-9) made them think that vibration indicators
are unreliable but on the 737-400 they were extremely reliable.
But as a crew, failing to monitor the engine instruments properly is the problem.
Shutting down an engine is a critical decision; you must be sure which engine it is and confirm
before doing that.

F - FACTS
O - OPTIONS
R - RISKS
D - DECISION
E - EXECUTE
C - CHECK

Out of the FORDEC model, captain tried to CHECK the decision they made, which was interrupted
by ATC, if he persuaded that CHECK, maybe they could’ve managed to restart the engine.

Crew also could’ve used more of the resources they had, the cabin crew which has a direct visual
contact with engines could’ve identified the faulty engine better than the crew since the flames
were visible. From the other side of the equation, cabin crew didn’t give enough attention to PA
since they were busy with the landing checks they had to make in the cabin.
Even passengers were confused with the PA, when captain said it was the right engine the
problematic one, none of them brought it up to the cabin crew.

This accident was a preventable accident, the proper decision making and using more resources
available could’ve prevented that.