just minutes after takeoff from London heat thr a Boeing 737 carrying 126 passengers and crew is in serious trouble the aircraft has begun to shake violently and a sickening smell of burning has filled the air orange flashes light up the passenger cabin as one of the engines begins tearing itself to Pieces the pilot shut down an engine and begin limping their crippled jet back to the airport but then at the last minute the captain has a horrifying realization they have shut down the wrong engine how did such an experienced crew make such a basic mistake and would they be able to fix it before time run out this is the story of British Midlands flight [Music] 92 it was a cold January evening in 1989 as 118 passengers and eight crew boarded a brand new Boeing 737 400 at London's heat throw airport they were Bound for Belfast in Northern Ireland a short 1our Journey many of the passengers were business Travelers returning home to Belfast after a trip to London While others were families visiting loved ones in Belfast and tourists returning home from the UK's Capital there were also five cabin crew on board and two pilots in command of the flight was 43-year-old Captain Kevin hunt hunt was one of British Midland's most experienced Pilots having joined the airline 22 years previously in 1966 at the age of 20 he had flown a wide range of aircraft in that time and had built up an impressive 13,000 was a flying experience on this evening though certain parts of this experience would end up being not a blessing but a curse sitting to Hunt's right was 39-year-old first officer David mcland mcland had just over 3,000 hours of experience most of which were on smaller propeller driven aircraft he had joined British Midlands the previous year when he had been signed off to fly the 737 in this time he had built up just short of 200 hours on it neither pilot was a total stranger to the Boeing 737 having a Mas almost 1,000 hours on the aircraft between them but they were new to this particular variant of the 737 the 400 series which had just been introduced the previous year the new plane had an upgraded cockpit with modern CRT displays replacing the older analog gauges of the past this was Boeing's response to the emerging threat that was Airbus which just that year had released its ultr modern A320 as a direct competitor to the 737 according to Boeing the Pilot's lack of experience on this new aircraft shouldn't have posed any problems in what could be described as a signature move from the company they had convinced regulators and airlines that Pilots with previous 737 experience didn't need any Advanced Training like simulator time to fly the new 737 all they required was a few hours in the classroom and a pamphlet before they would be ready to sit behind the controls of Boeing's newest addition to its product line This reduced need for training saved Airlines millions and it saved Boeing even more in both time and certification costs by comparison for an airline to buy air bu's latest offering it would have to send its Pilots to the classroom and to a full motion flight simulator for months on end at a cost of around $1,000 per hour the passengers of flight 92 were now about to pay dearly for Boeing's tactical marketing decisions that's because there was more to this new iteration of the 737 than met the ey there had been some significant changes to the way in which information was presented to the pilots and to some of the aircraft's key systems such as its air conditioning and pressurization system as the doors were sealed and the aircraft was pushed back from the gate at heat thr none of the passengers could have known that up front were two pilots who had never had the opportunity to practice any infight emergencies or procedures in a 737-400 simulator first off from mcland taxied the brand new plane out to the runway at hro navigating the complex taxiway system while the captain carried out the predeparture checks before we get to 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altitude of 35,000 ft the passengers settled in for the short trip with some of them eating dinner others reading and others chatting amongst themselves but this normality would be shortlived barely 15 minutes after takeoff as it climbed through 28,300 ft the plane began to shake violently overhead bins popped open and drinks and personal items began sliding off passenger trade tables loud banging noises shook the aircraft and intermittent Flames from an engine lit up the passenger cabin then a horrifying smell seeped into the cabin of burning oil Rubber and hot metal in the cockpit the pilots immediately looked at their engine instruments these next few seconds would be crucial hunt and mcland would need all of their mental resources to quickly and accurately determine the source and nature of the problem and to carry out the appropriate procedures to resolve it but at this critical juncture Captain hunt made a split-second decision which would end up endangering the lives of everybody on board the aircraft rather than bringing his vast experience to bear on the problem he saw before him he gave that job to the less experienced first officer and took over manual control of the aircraft himself now the more experienced crew member was doing the relatively simple yet attention consuming job of flying the plane manually while the less experienced one was almost single-handedly responsible for diagnosing the Urgent problem with the aircraft as the first off scan the instruments the captain was building a mental picture of the problem in his head he had many arrows on the previous generation of the 737 and he knew that on that aircraft the Ford cabin was fed air by the right hand engine since he could smell burning it made sense that the problem should be with the engine responsible for bringing air into the cabin which in his experience was the right-and engine what neither pilot knew was that on the 737 400 the cabin air comes from both engines so in reality the fact they smelled smoke told them nothing about which engine was having problems but Pilots don't make serious decisions like shutting down an engine based on their sense of smell thankfully on this night they had at their disposal some state-of-the-art instrumentation the vibration meter for engine number one the left- hand engine was indicating five units of vibration the maximum that the instrument could display the N1 indication which showed the fan speed at the front of the engine was fluctuating radically the exhaust gas temperature indicator was showing much higher values than normal and the fuel full readings were varying Wild by contrast all indications for the right hand engine engine number two were normal the instruments were painting a very clear picture the leftand engine was having serious problems but when Captain hunt asked the first officer which engine was having issues mlen hesitated in modern aircraft the engine vibration meters are located on a screen the left meter indicates the vibrations from the left engine and the right meter from the right engine this instrument is one of the most important indicators of any issue with the engines and it's where mlen was now focusing his attention however in the 737 400 engine layout both engine vibration meters were located on the right hand side of the engine instrument panel in the stress of the moment as the first officer quickly took in the instrument readings he saw a high vibration reading coming from the right hand side of the instrument panel to make matters worse in a cruel Twist of irony the very vibration whose Source the pilots were trying to locate was so severe that it made it difficult for them to read the instruments this effect was made worse by phenomen known as Persistence of vision where in a dark environment our eyes retain a trace of any light sources we look at for about a second all of these effects swirled together into a perfect storm such that when mlen looked at his instruments he hesitated before saying it's the it's the right one Captain Hunt's suspicions were confirmed he had already thought that it was the right hand engine given that he could smell smoke he told mcland to throttle the engine back but the pilots were wrong the engine instruments for the right hand engine showed that it was working perfectly it was the left engine that was tearing itself to pieces this was something that the passengers in Cabin crew were all too well aware of they could see Sparks and jets of flames shooting back from behind the left engine they had no idea that up front in the cockpit with all of their instrumentation the pilots had missed this crucial fact but just before the first officer throttled the engine back there was one last clue that they had misidentified the problematic engine and it was a big clue staring them right in the face in the 11 seconds since the captain had disengaged the autopilot and taken over from the first officer the plane had begun a roll to the left in that short time it had actually reached a bank angle of 16° a pretty substantial departure from straight and level flight the reason this was such a big clue is that the captain hadn't caused this turn the engines had with the fully functioning right hand engine working at its normal power setting and the sputtering left hand engine producing much less thrust than normal the aircraft had begun to be pushed to the left this difference in thrust was giving a clear clue to the pilots that the problematic engine was the leftand one if it had been daytime the pilots would clearly have been able to see this turn happening but in the dark with nothing to see out the windows the only clue that they were turning came from the small Artificial Horizon in front of them and they were so busy focusing on the engine instruments that they simply didn't notice this turn happening when the captain finally did catch the aircraft he didn't stop and think about why the plane had turned so much towards what he thought was the good engine he simply leveled the wings and continued flying but all of these missed Clues were nothing compared to what would come next naturally you would expect that as the first officer reduced power on the right hand engine the vibrations and the smell of smoke would remain clearly showing that the left- hand engine was the problem that is not what happened here that's because as m brought the right hand engine lever back to idle the captain reduced power on the left hand engine too in order to descend and as the left engine was BR back to Idol the vibrations stopped and the smell of smoke disappeared the pilots had received a misleading Vindication of their decision to throttle back the right hand engine as far as they were concerned they had just executed a textbook identification and resolution of an inflight emergency the rest of the flight would consist of them finding an airport to divert to and informing the passengers of the disappointing news that they wouldn't be getting to their destination tonight the reality was that when the pilots reduced power on both engines the excess fuel which was igniting inside the leftand engine causing the noise and vibrations had stopped coming into the engine this is what had made the vibration stop it had nothing to do with reducing power on the fully functional right hand engine despite this there was still ample opportunity for the pilots to realize their mistake their instruments were still showing the true story that all of their problems were with the leftand engine the first officer radio London Air Traffic Control telling them that they had an emergency situation which might be an engine fire there were no cockpit indications that there was a fire but realizing that there might indeed be one Captain hunt then told mcland to shut the engine down but before the first officer did this the captain took a look at the instruments and saw that the right engine was functioning normally he then told the first officer to hold off and shutting down the engine for the moment if hunt had just checked the instruments a few centimet to the left of the once he was looking at the truth would have been crystal clear the next few minutes were busy as the first officer coordinated the diversion with air traffic control and the captain radioed the company to inform them of the situation in the back the C crew told the passengers to fasten their seat bels the worst of the shaking had stopped but the passengers were still in the dark as to what was happening those sitting on the left hand side of the plane could see a stream of jet fuel pouring out of the engine but at least for now the fire had stopped after a few minutes the pilots decided on East Midlands as their diversion airport it was close to them the runway was long enough the weather was clear and it was British Midland's main engineering base so flight 92 began setting course for East Midlands as soon as he was off the radio the first officer announced that he was about to start the engine failure and shut down checklist for the right-and engine but just as he was about to start it he checked the engine instruments of course once again Engine 2 looked perfectly fine he said seems we've stabilized we've still got the smoke again he held off on the checklist and the right engine remained at idle but the Pilot's window of opportunity to notice the clear discrepancy between the two engine indications would be brief during a pause in the conversation between Captain hunt and the airlines operations center the first officer finally closed the right hand engine's fuel lever starved of fuel the fully functioning right hand engine began began to wind down mcleland then started the auxiliary power unit which took on some of the electrical load the withering left-hand engine had to produce once the right hand engine was shut down the pilots noticed that the smoke smell had cleared from the flight deck again this reinforced their belief that the right engine was causing the issue and that they had done the correct Thing by shutting it down but there was still hope that the pilots might realize the error of their ways in the back there were 118 passengers and and six cabin crew many of whom had witnessed the engine problems firsthand what better resource could a pilot ask for the captain called the cabin supervisor up to the cockpit nowadays in a similar situation a captain would provide what is known as a nits briefing to the cabin crew n stands for the nature of the emergency as in what has actually happened it is at this point the captain would ask if the crew or passengers had seen anything that could help in understanding the type of emergency they were in I stands for intention in this case the intention was to divert the aircraft to East Midlands T stands for time as in how long before the aircraft will be on the ground and S stands for a special or relevant information regarding the safety of those on board this covers things like whether the passengers will need to remain in their seats on Landing or if an evacuation will be required and if so whether all doors are available but back in the 1980s and 1990s this type of briefing had not yet been widely adopted so rather than doing a comprehensive brief or even asking what specifically the cabin crew had noticed hunt simply asked the cabin crew supervisor whether he had seen smoke in the cabin the supervisor said that he had and then hunt quickly instructed him to clear up the cabin and pack everything away in failing to get more information from his crew hunt deprived himself of the opportunity to find out that many of the crew and passengers had seen nothing on toward with the right engine but that they had seen plenty of evidence from the left- hand engine that it was not functioning correctly the cabin supervisor headed back to the passengers and began preparing them for the diversion flight 92 was now being vectored by London Air Traffic Control towards East Midlands it would be on the ground in less than 15 minutes the captain was still flying manually and talking to East Midlands operations while the first officer was dealing with air traffic control and with setting the aircraft up for its approach to the airport it was a busy time in the cockpit and the Pilot's workload would only increase as they got closer the passengers were growing increasingly concerned they were clearly now descending but the pilots had told them nothing about what was happening what were they to think of all the flames and smoke and smells and vibration the captain supervisor contacted the captain telling him that the passengers were beginning to panic hunt decided to make a PA in that PA he told the passengers that there had been an issue with the right-and engine which was responsible for producing the smoke they had seen in the cabin he also said that the engine was now shut down and that the aircraft would land at East Midlands Airport in around 10 minutes this PA confused the passengers many of them had seen the Flames coming from the left hand engine why had the captain just said that he had shut down the right hand engine perhaps he had misspoke they thought or maybe there had been something wrong with the right engine too that they just couldn't see out their Windows after all it was the pilots who had access to all the instrumentation open the cockpit surely they knew what they were doing even still not one of the passengers made a comment to any of the cabin crew about what the captain had said and the cabin crew too didn't question the captain's mention of the rightand engine flight 92 continued its descent towards East Midlands its left engine a ticking Time Bomb hidden simply by the fact that it was operating at a low power setting during [Music] descent as the flight neared East Midlands the atmosphere in the cockpit was heavy and the workload for both Pilots was high the first officer in addition to handling all the radio calls and getting the latest weather was also attempting to program the approach to Runway 27 into the flight management system In the Heat of the Moment and still relatively new to the aircraft he was having trouble doing this after a few minutes of trying mcleland abandoned his attempts at setting up the flight management computer the pilots would simply need to follow air traffic controls instructions to make it to the airport finally in a break between all of the communications with the ground Captain hunt decided to review the situation saying now what indications did we actually get just rapid vibrations in the airplane smoke this was the Pilot's chance here they could carve out a few minutes to engage the autopilot sit back and carefully work through the indications they had gotten and the actions they had taken before continuing their approach to the airport they had plenty of fuel and there was nothing forcing them to land immediately given that they thought they were flying on a fully functioning engine but just as they were about to begin this review of the situation Air Traffic Control interrupted them handing them off to the next controller on Route after talking to the controller rather than continuing the review of the situation the first officer began to read the checklist for a one engine in operative descent and approach the review they had just begun had been all but forgotten about even as mlen worked through this checklist he was continually interrupted by air traffic control who were giving the plane Des send clearances and heading instructions in all of this activity the pilots had allowed themselves to become overloaded with necessary but nonetheless non-critical items at a stage of the flight where it was crucial that they reviewed their highly consequential decision to shut down one of the engines finally after multiple interruptions the first officer managed to finish the single engine approach checklist the aircraft was now prepared for an approach on one engine and the pilots were mentally ready to carry it out this was something they had practiced many times in the flight simulator but this would be their first time carrying it out for real the plane was now 15 nautical miles from touchdown and descending through an altitude of 6,500 ft Captain hunt began slowing the aircraft and asked for the first stage of flaps to be extended things in the cockpit had been busy for the past few minutes but the aircraft itself appeared to be in good condition now all of that was about to change as the captain leveled off at 3,000 ft he increased the thrust on engine number one immediately the vibration meter went to maximum defle flection but already convinced that they had shut down the correct engine the pilots never thought to monitor it the engine was now under tremendous stress there was no guarantee that it would hold up until the plane touched down as he lined up with the runway hunt began descending again and called for further stages of flap the first officer extended the flaps to 15° and lowered the landing gear and fight 92 began its final descent towards the runway they now had less than five nautical miles to go until touching down with the flaps and gear extended the aircraft was now experiencing much more drag than before in order to keep his air speed up Captain hunt had to further increase the power on engine number one but when he did this the extreme vibrations returned Flames began shooting out the back of the engine and in the passenger cabin the shaking was so bad that many of the overhead lockers opened spewing their contents on top of the terrified passengers the engine was sputtering and his thrust output began to decrease the captain pushed the throttle lever forwards but this only made the problem worse the engine was now tearing itself apart just miles from the airport the runway now tantalizingly close began to slide up the Pilot's wind screens at just 900 ft above the ground and still 2 and 1 half miles from the runway the left engine gave up entirely there was a sickening feeling as the plane now powerless began to drop Captain hunt immediately ordered the first officer to start the right hand engine and mlen frantically began trying trying to relight it but there simply wasn't enough time the plane would reach the ground before the right engine would have time to spool up in a desperate attempt to stretch the Glide Hunt Raised the plane's nose but this had the opposite effect it actually increased the drag on the plane and made its descent angle even steeper with the plane slipping lower and lower it now looked increasingly unlikely that the pilots would be able to make the runway bells and warning sounds erupted in the cockpit with the grand proximity warning system alerting the to their deviation from the Glide slope the fire warning for engine number one ringing out and its red lights glowing in the center pedestal looking out their wind screens at the runway the pilots could clearly see that their situation was now unsalvageable the captain quickly got on the intercom and told the passengers to prepare for a crash landing as the aircraft speed fell below 125 knots the stick Shaker joined the cacapon in the cockpit it vibrated the Pilot's controls violently alerting them that the aircraft was about to stall this shaking continued all the way down as the plane sunk and then slammed into the ground just short of the M1 Motorway it then bounced across the road and smashed into a wooded area on the other side of the motorway the scene was one of utter Devastation with the aircraft breaking into three sections 47 passengers died and 66 more were seriously injured seven of the crew were also seriously injured including both Pilots but what had caused the engine problems to begin with and how could such an incredible response response as shutting down the wrong engine be prevented from happening in the future as a direct result of the crash all 99 of the 737 400s in service were grounded analysis of the engines determined that the fan blades of the upgraded engine used on the 737 400 were subject to abnormal amounts of vibration when operating at high power settings above 10,000 ft on flight 92 this vibration had led to excessive metal fatigue causing one of the fan blades to snap off during the climb to cruise altitude this critically damaged the engine and also upset the delicate balance of fuel and air causing a reduction in power and an increase in vibration which ultimately destroyed the engine when power was increased on Final Approach as a result of the crash the engines used in the 737 400 were redesigned so as to eliminate the vibration which caused metal fatigue but the biggest changes which resulted from this accident were not in engine manufacturer but in Pilot training Pilots now receive extensive training in crew resource management or CRM which includes the deliver of nits briefings to cabin crew modern training also emphasizes the need for Pilots to carefully review every decision that is made and to take as much time as is needed to do this safely rather than to act quickly and make a false diagnosis training also teaches Pilots to use automation to lighten their workload when appropriate in this accident Captain Hunt's decision to fly manually had diverted his attention away from identifying the problematic engine at a time when this was the most important thing for him to be focused on in subsequent versions of the 73 7 like the 737 NG and the 737 Max changes have been made to the way in which abnormal engine indications are displayed to the pilots color coding and highlighting are used to draw Pilots attention to critical or malfunctioning parameters after the accident Captain hunt and first officer mlen were dismissed following criticisms of their actions in the final report British Midlands later paid mcland an outof Court settlement for unfair dismissal and Captain hunt maintained that he and his fellow pilot were ousted because this was the easy option for the airline rather than taking a hard look at their training practices and at systemic issues in the industry whatever way you want to apportion responsibility here there is no denying that the impact of this accident on the aviation industry has been Monumental flying is now safer as a result of the lessons learned from flight 92 this video is dedicated to those who lost their lives so that these safety improvements could be made
