Crash of a Beechcraft E90 King Air in Bournemouth

Date & Time: May 18, 2011 at 1131 LT
Type of aircraft:
Registration:
N46BM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Bournemouth - Manchester
MSN:
LW-198
YOM:
1976
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
1
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
800
Captain / Total hours on type:
660.00
Circumstances:
The pilot had planned to fly from Bournemouth Airport to Manchester Airport operating the flight as a single pilot, with a passenger seated in the co-pilot’s seat. He arrived at the airport approximately one hour before the planned departure time of 1130 hrs, completed his pre‑flight activities and went to the aircraft at approximately 1110 hrs. The 1120 hrs ATIS gave the weather at the airport as: surface wind from 230° at 10 kt, visibility 10 km or greater, few clouds at 1,000 ft, broken cloud at 1,200 ft and at 2,000 ft, temperature 16°C, dew point 12°C and QNH 1015 hPa. After starting the engines, the pilot was cleared to taxi to holding point ‘N’ for a departure from Runway 26 and he was given clearance to take off at 1127 hrs. At 1129:45 hrs, approximately 55 seconds after the aircraft became airborne, the aerodrome controller transmitted “four six bravo mike do you have a problem?” because he believed the aircraft was not climbing normally. The pilot replied “november four six bravo going around” and, shortly afterwards, “four six bravo requesting immediate return”. The controller cleared the pilot to use either runway to land back at the airport but received no reply. The pilot carried out a forced landing into a field 1.7 nm west of the Runway 08 threshold at Bournemouth Airport and neither he nor his passenger was hurt.
Probable cause:
The pilot experienced symptoms of symmetrical power loss sufficient to prevent the aircraft from sustaining level flight and made a forced landing into a field. The deficiency in the aircraft’s takeoff performance suggested that its powerplants were not producing sufficient thrust. As fuel contamination was discounted and no fault was found in either engine, it was concluded that, in all probability, the poor performance was not caused by a failure in either powerplant. Maximum rpm was not selected for departure but it was unlikely that this explained the aircraft’s poor performance on the runway or in the air. The pilot insisted that he had set torque to the takeoff limit. There was insufficient evidence to enable the cause of the apparent power loss to be determined.
Final Report:

Crash of a Cessna 421B Golden Eagle II off Stauning

Date & Time: May 21, 1999 at 0002 LT
Operator:
Registration:
OY-BIM
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Stauning - Manchester
MSN:
421B-0878
YOM:
1974
Country:
Region:
Crew on board:
2
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
3706
Captain / Total hours on type:
361.00
Copilot / Total flying hours:
650
Copilot / Total hours on type:
54
Aircraft flight hours:
5518
Circumstances:
The twin engine aircraft departed Stauning Airport at 0000LT on a cargo flight to Manchester with two pilots on board. Shortly after takeoff from runway 27, while in initial climb by night, the crew declared an emergency after the main cabin door opened. The captain reduced both engines power and the aircraft crash landed on the Klægbanke, less than 4 km from the airport. Both pilots were rescued an hour later (they were uninjured) and the aircraft was damaged beyond repair.
Probable cause:
The main cabin door opened during initial climb because the crew failed to ensure it was properly closed. Investigations reported that the door locking mechanism was not properly adjusted and that the crew did not identify the abnormal situation. The following factors were identified:
- The captain immediately reduced power on both engines when the door opened,
- The captain was not properly trained,
- The operator did not ensure that the crew was qualified and trained to perform this type of flight,
- The crew failed to follow the pre departure checklist,
- The crew's attention was focused on the door that opened at a critical moment of the flight and failed to continue the flight and monitor the various instruments.
Final Report:

Crash of a Partenavia P.68B in East Midlands: 1 killed

Date & Time: Oct 20, 1990 at 0332 LT
Type of aircraft:
Operator:
Registration:
G-BMCB
Flight Phase:
Flight Type:
Survivors:
No
Schedule:
East Midlands – Manchester
MSN:
156
YOM:
1985
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
1
Captain / Total flying hours:
926
Circumstances:
The twin engine aircraft departed East Midlands runways 27 on a ferry flight to Manchester. During initial climb by night, the aircraft entered an uncontrolled descent and crashed at a speed of 160 knots and disintegrated in a field near the airport. The pilot, sole on board, was killed.
Probable cause:
Loss of control during initial climb by night after the pilot suffered a spatial disorientation due to the combination of a poor visibility (night and low clouds) and the possible malfunction of the horizontal stabilizer due to water in the vacuum system.
Final Report:

Crash of a Britten-Norman BN-2B-27 Islander in Ainsdale

Date & Time: Aug 21, 1987 at 0530 LT
Type of aircraft:
Operator:
Registration:
G-BLDX
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Manchester – Douglas
MSN:
2181
YOM:
1983
Region:
Crew on board:
1
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
0
Captain / Total flying hours:
11792
Captain / Total hours on type:
17.00
Circumstances:
A Britten-Norman BN-2B-27 Islander sustained substantial damage in a forced landing on a Merseyside beach. The airplane was to carry mail on an early morning service from Manchester Airport (MAN) to Ronaldsway Airport, Isle of Man. The commander arrived at the aircraft at about 03:45 hrs in the morning. As it was dark, the internal checks were done in normal cockpit lighting and, having completed the usual preflight administration, he was ready to start engines at about 04:50 hrs. The aircraft took off at 05:09 hrs, on a Special Visual Flight Rules Clearance, turned right onto a northwesterly heading, and climbed to an initial cruising altitude of 1000 feet. Just prior to crossing the coast, as conditions were conducive to the formation of carburettor icing, the commander selected HOT air on both engines for 30 seconds. At this stage the aircraft was cruising at an altitude of 2000 feet at between 120 and 130 knots with both engines set at 24 inches manifold pressure and 2300 revolutions per minute. When the aircraft was about 2 nautical miles out to sea, the port engine appeared to surge and then stopped. Shortly afterwards, the starboard engine did the same thing. At 05:28 hrs the commander informed Liverpool Approach that he had a problem and was going to attempt a forced landing at Woodvale Airfield. Having turned back towards the shore, the commander selected the TIP/MAIN switch to TIP and reduced the indicated airspeed to about 65 kt in the descent. The aircraft did not reach Woodvale and a forced landing was carried out on the beach. It was while the commander was making the aircraft safe that he noticed that the main fuel cock selectors were positioned such that both engines had been feeding from the right fuel tank. Both fuel cocks were then selected to OFF and, when the shutdown had been completed, the commander vacated the aircraft uninjured. The aircraft had landed on flat sand, but had struck a soft patch; this had resulted in the collapse of the nose and right main undercarriage, and damage to the nose and the wing centre section. Recovery attempts by local services had severely damaged the tailplane and had probably caused the sideway failure of the left undercarriage. The aircraft was totally submerged during the subsequent high tide. Examination of the aircraft, before it was recovered from the beach, showed no evidence of any pre-impact failure in the engine or flying controls. The fuel state was approximately 289 litres with the right main tank empty.
Probable cause:
Double engine failure caused by a fuel exhaustion as the fuel selector was positioned on an empty tank. 289 liters of fuel remained in other tanks at the time of the accident.
Final Report:

Crash of a Boeing 737-236 in Manchester: 55 killed

Date & Time: Aug 22, 1985 at 0713 LT
Type of aircraft:
Operator:
Registration:
G-BGJL
Flight Phase:
Survivors:
Yes
Schedule:
Manchester - Kerkyra
MSN:
22033
YOM:
1981
Flight number:
KT328M
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
131
Pax fatalities:
Other fatalities:
Total fatalities:
55
Captain / Total flying hours:
8441
Captain / Total hours on type:
1276.00
Copilot / Total flying hours:
12277
Copilot / Total hours on type:
345
Aircraft flight hours:
12977
Aircraft flight cycles:
5907
Circumstances:
British Airtours Flight 328 (also known as flight 28M) was a charter flight from Manchester to Corfu. At 06:08 in the morning the crew were cleared to taxi to runway 24 for departure. At 06:12 the aircraft had lined up on the runway and was cleared for takeoff. The takeoff was to be performed by the co-pilot. During the takeoff run the captain made the routine 'eighty knots' call and 12 seconds later a 'thump' or 'thud' was heard. The captain immediately ordered 'stop', closed the throttles an selected reverse thrust. The maximum speed achieved was 126 knots IAS. At first the captain thought they had suffered a tyre burst or a bird strike. The co-pilot had applied maximum wheel braking, however, because of the possible tyre burst, the captain said 'Don't hammer the brakes, don't hammer the brakes'. At 45 seconds after the start of the takeoff run, 9 seconds after the 'thud', as the aircraft decelerated trough 85 knots the captain radioed ATC that they were abandoning takeoff. The fire bell rang simultaneously and he added as he cancelled reverse thrust, 'it looks as though we've got a fire on number 1'. ATC confirmed this: 'right there's a lot of fire, they're on their way now.'. At 25 seconds past the 'thud' (and 20 seconds before the aircraft stopped) the crew decided to evacuate via the starboard side. The 737 was decelerating through 36 knots then and the captain warned the cabin crew about the evacuation six seconds later. After the aircraft stopped a no. 1 engine fire drill was carried out, the no. 2 engine was shut down and the passenger evacuation drill carried out. Before completion of this drill the captain saw fuel and fire spreading forward on the left side of the aircraft. Both flight crew members escaped through the sliding window in the right hand side. Immediately after the 'thud' an intense fire developed on the left-hand side of the plane, causing some cracking and melting of windows with some associated smoke in the aft cabin. This caused some passengers to stand up in alarm and move into the aisle. Immediately after coming to a halt the purser tried to open the right front door (R1) but the escape slide container jammed on the doorframe, preventing further movement of the door. He then crossed to the L1 door and opened it (25 seconds had passed since the aircraft had stopped). The purser then returned to the R1 door and managed to clear the obstruction and was able to open the door 85 seconds after the aircraft had stopped. Meanwhile passengers had managed to open the right hand overwing exit. The R2 (right rear) door had also been opened but no one escaped through this exit. In total 17 surviving passengers escaped through the L1 door, 34 through R1 and 27 through the overwing exit.
Probable cause:
The cause of the accident was an uncontained failure of the left engine, initiated by a failure of the No 9 combustor can which had been the subject of a repair. A section of the combustor can, which was ejected forcibly from the engine, struck and fractured an underwing fuel tank access panel. The fire which resulted developed catastrophically, primarily because of adverse orientation of the parked aircraft relative to the wind, even though the wind was light. Major contributory factors were the vulnerability of the wing tank access panels to impact, a lack of any effective provision for fighting major fires inside the aircraft cabin, the vulnerability of the aircraft hull to external fire and the extremely toxic nature of the emissions from the burning interior materials. The major cause of the fatalities was rapid incapacitation due to the inhalation of the dense toxic/irritant smoke atmosphere within the cabin, aggravated by evacuation delays caused by a forward right door malfunction and restricted access to the exits.
Final Report:

Crash of a Boeing 727-64 in Tenerife: 146 killed

Date & Time: Apr 25, 1980 at 1321 LT
Type of aircraft:
Operator:
Registration:
G-BDAN
Survivors:
No
Site:
Schedule:
Manchester - Tenerife
MSN:
19279
YOM:
1966
Flight number:
DA1008
Country:
Region:
Crew on board:
8
Crew fatalities:
Pax on board:
138
Pax fatalities:
Other fatalities:
Total fatalities:
146
Captain / Total flying hours:
15299
Captain / Total hours on type:
1912.00
Copilot / Total flying hours:
3492
Copilot / Total hours on type:
618
Aircraft flight hours:
30622
Circumstances:
Dan-Air flight 1008 took off from Manchester Airport (MAN) at 09:22 UTC en route for Tenerife-Norte Los Rodeos Airport (TFN). After an uneventful flight, the crew contacted Tenerife North Airport Approach Control at 13:14, informing them that they were at FL110 and at 14 nautical miles from the TFN VOR/DME. Approach Control replied, "Dan Air one zero zero eight, cleared to the Foxtrot Papa beacon via Tango Foxtrot November, flight level one one zero expect runway one two, no delay." The Dan Air crew repeated the clearance and requested meteorological information, which was given as: "OK runway in use one two, the wind one two zero zero five, visibility six from seven kilometres clouds, two oktas at one two zero metres, plus four oktas at two five zero metres, plus two oktas at three five zero metres, November Hotel one zero three, temperature one six, dew point one, and drizzle." Approximately one minute later Approach Control told the aircraft to descend and maintain FL60. Receipt of this message was acknowledged by the aircraft, whereupon the controller immediately requested it to indicate its distance from the TFN beacon. The crew replied that it was at 7 NM from TFN. At 13:18:48 UTC the aircraft notified Approach Control that it had just passed TFN and that it was heading for the 'FP' beacon. The controller then informed them of an unpublished hold over Foxtrot Papa: "Roger, the standard holding over Foxtrot Papa is inbound heading one five zero, turn to the left, call you back shortly." Dan Air 1008 only replied "Roger" without repeating the information received, which was not compulsory under the ICAO regulations in force at the time of the accident. Almost one minute later, the aircraft the crew reported: "Dan Air one zero eight, Foxtrot Papa level at six zero, taking up the hold" and Tenerife APP replied: "Roger". Instead of passing overhead FP, the flight had passed this navaid at 1.59 NM to the South. Instead of entering the 255 radial, the Boeing 727 continued its trajectory in the direction of 263 degrees for a duration of more than 20 seconds, entering an area with a minimum safety altitude (MSA) of 14500 ft. The co-pilot at that point said: "Bloody strange hold, isn't it?" The captain remarked "Yes, doesn't isn't parallel with the runway or anything." The flight engineer then also made some remarks about the holding procedure. Approach control then cleared them down to 5000 feet. The captain then remarked: "Hey did he say it was one five zero inbound?". It appears that at this moment the information received on the holding flashed back to the Captain's mind, making him realize that his manoeuvre was taking him to magnetic course 150 degrees outbound from 'FP', whereas the information received was "inbound" on the holding, heading 150 degrees towards 'FP'. The copilot responded: "Inbound yeh". "I don't like that", the captain said. The GPWS alarm sounded. The captain interrupted his left hand turn and entered a right hand turn and ordered an overshoot. They overflew a valley, temporarily deactivating the GPWS warning. The copilot suggested: "I suggest a heading of one two two actually and er take us through the overshoot, ah." But the captain continued with the turn to the right, because he was convinced that the turn he had been making to the left was taking him to the mountains. The captain contacted Approach Control at 13:21: "Er ... Dan Air one zero zero eight, we've had a ground proximity Warning." About two seconds later the aircraft flew into the side of a mountain at an altitude of approximately 5450 ft (1662 m) and at 11.5 km off course.
Probable cause:
The captain, without taking into account the altitude at which he was flying, took the aircraft into an area of very high ground, and for this reason he did not maintain the correct safety distance above the ground, as was his obligation. Contributing factors were:
a) the performance of a manoeuvre without having clearly defined it;
b) imprecise navigation on the part of the captain, showing his loss of bearings;
c) lack of teamwork between captain and co-pilot;
d) the short space of time between the information given and the arrival at 'FP';
e) the fact that the holding was not published" (Spanish report)
UK authorities agreed in general with the report, but added some comments to give the report 'a proper balance':
1. the information concerning the holding pattern at FP, which was transmitted by ATC, was ambiguous and contributed directly to the disorientation of the crew;
2. no minimum safe altitude computed for holding pattern;
3. track for holding pattern at 'FP' is unrealistic.
Final Report:

Crash of a Vickers 815 Viscount in Manchester: 3 killed

Date & Time: Mar 20, 1969
Type of aircraft:
Operator:
Registration:
G-AVJA
Flight Phase:
Flight Type:
Survivors:
Yes
Schedule:
Manchester - Edinburgh
MSN:
336
YOM:
1959
Region:
Crew on board:
4
Crew fatalities:
Pax on board:
0
Pax fatalities:
Other fatalities:
Total fatalities:
3
Circumstances:
The crew (two pilots and two flight attendants) was completing a positioning flight to Edinburgh-Turnhouse Airport. Both pilots took the opportunity to make some training and decided to simulate an engine failure at takeoff. Shortly after liftoff at Manchester-Ringway Airport, while in initial climb, the crew shut down the engine n°4 and feathered its propeller when the airplane started to yaw sharply to starboard. Control was lost then the aircraft crashed inverted and burst into flames. A flight attendant was injured while three other occupants were killed.
Crew:
I. Wallace, pilot, †
R. A. Weeks, copilot, †
S. Wallis, stewardess, †
Jane Timson, stewardess.

Crash of a Canadair C-4 Argonaut in Manchester: 72 killed

Date & Time: Jun 4, 1967 at 0909 LT
Type of aircraft:
Operator:
Registration:
G-ALHG
Survivors:
Yes
Site:
Schedule:
Palma de Majorca - Manchester
MSN:
153
YOM:
1949
Region:
Crew on board:
5
Crew fatalities:
Pax on board:
79
Pax fatalities:
Other fatalities:
Total fatalities:
72
Captain / Total flying hours:
10197
Captain / Total hours on type:
2009.00
Copilot / Total flying hours:
1001
Copilot / Total hours on type:
136
Circumstances:
The aircraft was on a non-scheduled international flight from Manchester to Palma and return. It landed at Palma at 0220 hours GMT, was refuelled and took off for Manchester at 0406 hours GMT. The co-pilot was flying the aircraft from the right-hand seat and the flight was uneventful - between 0856 hours and 0900 hours the aircraft was descending for approach and landing and was being vectored towards the ILS localizer. At 0901:30 hours the flight was informed that it was 9 miles from touchdown and well left of the centre line and it was asked if it was receiving the ILS. The pilot-in-command replied that he was and would turn right a little. Shortly thereafter one engine, most probably No. 4, ceased to deliver power, followed some 15 seconds later by the other engine on the same side. The pilot-in-command took over the controls and just after 0903 hours the Controller told the flight that it was 6 miles from touchdown and asked if it was established on the ILS localizer. This message was not acknowledged by the flight and 7 seconds later the Controller asked if it was still receiving. The pilot-in-command then replied "Hotel Golf is overshooting, we've got a little bit of trouble with rpm". The aircraft's indicated air speed was then only 116 kt and its height 1 838 ft AMSL. The Controller then ordered the pilot-in-command to turn left on to 160'~ and climb to 2 500 ft QNH. He then asked the reason for overshooting and was told "We've a little bit of trouble with rpm, will advise you". At 0903:51 hours the pilot-in-command asked what the left turn was on to. The Controller noted that the aircraft had already turned through 25' to the right instead of to the left, so he ordered the pilot to continue turning right on to 020' and climb to 2 500 ft on QNH. This was acknowledged by the co-pilot. At 0904:41 hours the Controller asked the flight to advise when ready to recommence the approach. By this time the aircraft's IAS had dropped to 111 kt, its height to 1 287 ft ONH, and it had broken cloud and was seen by an eyewitness. Thereafter it flew below cloud in conditions of reasonable visibility. At 0905:26 hours the Controller told the flight that it was 7 miles from the airfield on a bearing of 040' and requested its height. The flight reported at 1 000 ft. This was the first indication to the Controller that the aircraft was faced with an emergency and after checking that the height given was correct he put full emergency procedure into operation at the airfield and ordered the aircraft to turn right on to 180 M, so that it would close the ILS localizer. At 0905:47 hoursthe Controller asked the flight if it could maintain height. The pilot-in-command now at 981 ft AMSL and only some 800 ft above the ground replied "just about". He was told he was 8 miles from touchdown and should continue his right turn on to 200% and maintain as much height as possible. At this point 341 ft of height were lost in 10 seconds after the IAS had fallen to 100 kt and the pilot-in-command said he was not able to maintain height at the moment. The Controller told him that he was 8 miles from touchdown and closing the ILS localizer from the right. At 0907:09 hours, the Controller informed the flight that radar contact had been lost due to the aircraft's low height and asked the pilot to adjust his heading on the ILS and report when established. The co-pilot replied that they had "the lights to our right'' and were at 800 ft, just maintaining height, and the pilot-in- command asked for the emergency to be laid on. At 0907:35 hours the pilot-in-command requested his position and was told 7; miles to run to touchdown. Half a minute later the Controller repeated that he had no radar contact, and cleared the flight for landing, the surface wind being 270°/12 kt. At this stage the PAR Controller, who had overheard that the Approach Controller had lost radar contact, saw a contact at the bottom of his elevation display, and told the flight that it was 6 miles from touchdown. The co-pilot then gave their altitude as being 500 ft. The terrain clearance was only 300 ft and the IAS was below 105 kt and falling. The aircraft was approximately on the line of the ILS localizer and heading for the very centre of the built up area of Stockport. A few seconds after 0909 hours the aircraft struck the ground more or less level in pitch, slightly right wing down, and slightly yawed to the right. From the evidence of two eyewitnesses who saw the aircraft just before the crash it was clear the pilot-in-command deliberately cut the power very shortly before impact and deliberately put the aircraft down on what was the only pocket handkerchief of relatively open space available, immediately before tall blocks of flats, the town hall, the police station, and Stockport Infirmary. Three crew members and 69 passengers were killed while 12 other occupants were injured.
Probable cause:
The immediate cause of the accident was loss of power of both engines on the starboard side resulting in control problems which prevented the pilot from maintaining height on the available power with one propeller windmilling. The loss of power of the first engine was due to fuel starvation due to inadvertent fuel transfer in flight. The loss of power of the second engine was due either to fuel starvation resulting from inadvertent fuel transfer in flight or to misidentification by the crew of which engine had failed followed by failure to restore power in time to the engine misidentified as having failed. Contributory causes of the accident were:
- The design of the fuel valves and location in the cockpit of their actuating levers, so that a failure by the pilot correctly to position the lever by an amount so small as to be easy to do and difficult to recognize would result in inadvertent fuel transfer on a scale sufficient to involve the risk after a long flight of a tank expected to contain sufficient fuel being in fact empty,
- Failure of those responsible for the design of the fuel system or the fuel valves to warn users that failure by a small amount to place the actuating levers in the proper position would result in inadvertent fuel transfer on a scale involving this risk after a long flight,
- Failure of British Midland's air crew or engineers to recognize the possibility of inadvertent fuel transfer in the air from the evidence available in previous incidents in flight and contained in the fuel logs,
- Failure of other operators of Argonauts who had learned by experience of the possibility of inadvertent fuel transfer in flight to inform the Air Registration Board, the Directorate of Flight Safety of the Board of Trade or its predecessors, or the United Kingdom Flight Safety Committee of the facts which they had learned so that these might be communicated to other operators of Argonauts and other aircraft equipped with similar systems and fuel cocks.
Final Report:

Crash of a Bristol 170 Freighter 21 at Winter Hill: 35 killed

Date & Time: Feb 27, 1958 at 0945 LT
Type of aircraft:
Operator:
Registration:
G-AICS
Flight Phase:
Survivors:
Yes
Site:
Schedule:
Douglas – Manchester
MSN:
12762
YOM:
1946
Region:
Crew on board:
3
Crew fatalities:
Pax on board:
39
Pax fatalities:
Other fatalities:
Total fatalities:
35
Circumstances:
The aircraft, operated by Manx Airlines Ltd, took off at 0915LT from Ronaldsway Airport, Isle of Man, on a flight to Ringway Airport, Manchester. It carried 39 passengers and a crew of 3. At approximately 0945LT the aircraft crashed near the summit of Winter Hill, killing 35 of the 42 persons aboard. All five crew members survived but were seriously injured. The aircraft was destroyed upon impact.
Probable cause:
The accident was attributed to the error of the first officer in tuning the radio compass on Oldham Beacon Instead of on Wigan Beacon. A contributory cause was the failure of the captain to check that the radio compass was tuned on the correct beacon.
Final Report:

Crash of an Airspeed AS.57 Ambassador 2 in Munich: 23 killed

Date & Time: Feb 6, 1958 at 1603 LT
Type of aircraft:
Operator:
Registration:
G-ALZU
Flight Phase:
Survivors:
Yes
Schedule:
Belgrade – Munich – Manchester
MSN:
5217
YOM:
1951
Flight number:
CY609
Country:
Region:
Crew on board:
6
Crew fatalities:
Pax on board:
38
Pax fatalities:
Other fatalities:
Total fatalities:
23
Captain / Total flying hours:
7337
Captain / Total hours on type:
1722.00
Copilot / Total flying hours:
8463
Copilot / Total hours on type:
3143
Circumstances:
The aircraft had carried out a special flight on 3 February 1958, from England to Belgrade, making an intermediate landing at Munich-Riem Airport for refuelling purposes. On 6 February it flew back from Belgrade, bound for Manchester. As planned, it again made an intermediate landing at Munich to refuel, landing there at 1417LT. The aircraft made three attempts at take-off, two were abandoned, and the accident occurred during the third attempt. The copilot abandoned the first take-off because the boost pressure readings of both engines showed upward variations, rising 2 or 3 inches above the usual reading of 57.5 inches. The second attempt to take-off followed immediately after the aircraft had taxied back to the beginning of the runway. The engine run-up was not repeated. The captain abandoned the second take-off because the boost pressure reading (this time on the port engine only) again rose beyond the normal maximum value to 60 inches. In each case the take-off was abandoned approximately half way down the runway. After the second attempt the aircraft continued rolling as far as the end of the runway and from there proceeded to the terminal building. The passengers disembarked, and the BEA station engineer went aboard. He then pointed out to the two pilots that the variations in boost pressure were connected with the elevation of Munich Airport. After a short discussion, the pilots decided to make a third (attempt at) take-off, and the passengers were told to board the aircraft again. Before the fresh (attempt to) take- off, a further engine run-up was carried out. After take-off had begun, the boost pressure reading of the port engine again fluctuated somewhat, but this ceased after the captain had throttled back slightly for a short time. After he had opened up the throttle fully again, no further fluctuation were observed. The aircraft never became airborne in the course of the third attempt at take-off. It traveled on over the whole length of the runway and the adjoining grass-covered stopway (250 m). At the end of the stopway it crashed through a wooden fence which marked the aerodrome boundary, cleared a secondary road and struck a house standing on the other side of the road. The left wing was torn off outboard of the engine mounting. Parts of the tail unit were also torn off here. The house caught fire. The aircraft then crashed into a wooden hut standing on a concrete base about 100 m further on, striking it with the right side of the rear section of the fuselage. The fuselage was torn away on a level with the trailing edge of the wing. The hut and the part of the fuselage which was torn away caught fire. The remainder of the aircraft wreckage slid on for a further 70 m. Of the 44 occupants (6 crew and 38 passengers) on board, 21 were killed instantly. The others received injuries of a more or less serious nature. Two died later in hospital as a result of their injuries. The house which was struck by the aircraft was badly damaged by fire. The hut was destroyed by fire. Among those killed were eight players and the trainer. The president of the club and ten other players survived the accident.
Probable cause:
During the stop of almost two hours at Munich, a rough layer of ice formed on the upper surface of the wings as a result of snowfall. This layer of ice considerably impaired the aerodynamic efficiency of the aircraft, had a detrimental effect on the acceleration of the aircraft during the take-off process and increased the required unstick-speed. Thus, under the conditions obtaining at the time of take-off, the aircraft was not able to attain this speed within the rolling distance available. It is not out of the question that, in the final phase of the take-off process, further causes may also have had an effect on the accident. British tests on the effect of slush on the takeoff process of an aircraft led the Luftfahrt-Bundesamt to decide to re-open the investigation in November 1964. In August 1966 the Commission arrived at the view that in the runway conditions obtaining at Munich-Riem at the time of the accident, the aircraft G-ALZU without ice on the wing upper surfaces could have attained the required unstick-speed and would have been bound to have done so. The failure to unstick, and hence the accident, are thus to be attributed to a series of inter-related causal factors viz.:
- Decrease in the lift coefficient resulting from ice on the wing upper surfaces and a consequent increase in the minimum unstick speed,
- Increase in drag caused by ice accretion, particularly at the higher angle of incidence during the unstick process,
- Reduction by slush and spray of the margin of performance of the aircraft and effect of the slush on the trim.
The differing assessments of the situation by the two pilots during the final phase of the take-off to be inferred from Captain Thain's statements resulted in their acting in opposition which probably increased the severity of the accident.
Final Report: