- British Midland B737 Flight 92 at Kegworth
- Accident Overview
- Accident Board Findings
- Accident Board Recommendations
- Relevant Regulations
- Prevailing Cultural / Organizational Factors
- Key Safety Issue(s)
- Safety Assumptions
- Resulting Safety Initiatives
- Airworthiness Directives (ADs) Issued
- Common Themes
- Related Accidents / Incidents
- Lessons Learned
- British Midland B737 Flight 92 at Kegworth
Resulting Safety Initiatives
No specific regulatory changes were identified as a result of this accident. However, two major safety areas were influenced by the British Midlands Flight 92 accident:
Photo of Seats in mid-cabin area of British Midlands Flight 92
Seat Structural Integrity
Rulemaking requiring aircraft seats to withstand 16g accelerations was in place at the time of this accident. However, airlines had not been required to retrofit cabins to install the stronger seats on airplanes manufactured prior to the effective date of the rule, such as the British Midlands flight 92 Boeing 737. While seats that were compliant with the new 16g standards were not required to be installed, flight 92 was equipped with upgraded seats that performed better than the older 9g seats would have been expected to perform. Investigation into seat performance showed that the installed, upgraded seats, did in fact provide improved protection from injury relative to 9g seats, Investigators concluded that the upgraded 16g seat standards had been an appropriate and necessary safety improvement.
Inappropriate Crew Response to Malfunctions
British Midlands Flight 92 experienced a failure condition which should not have resulted in a catastrophic outcome. The fan blade failure, while resulting in substantial engine damage, did not pose a structural or controllability threat to the airplane. However, the inappropriate response by the flight crew, in shutting down the healthy engine, placed the aircraft in a hazardous condition which was not recognized until it was too late to restart the engine. The circumstances of a benign, or low-hazard condition, followed by an inappropriate crew response has led to a number of accidents. Faulty landing gear indicator lights, tire failures during takeoff, misleading avionics indications, sudden in-flight upset encounters, and other singular events have, when accompanied by an inappropriate flight crew response, occasionally resulted in a catastrophic outcome.
Specifically, in the area of inappropriate crew responses to propulsion malfunctions (such as occurred on flight 92) a 1993 Aerospace Industries Association (AIA) report noted that, as of the report date, a "substantial number of incidents and accidents had occurred with similar links in the causal chain." The report cited that approximately three accidents per year worldwide were a result of inappropriate crew responses to propulsion malfunctions.
In December, 1994, a British Aerospace Jetstream 3100 crashed while on an instrument approach to Raleigh-Durham, North Carolina. The National Transportation Safety Board (NTSB) identified an incorrect crew response to a momentary propulsion malfunction indication as a primary cause of the accident. The captain incorrectly assumed that an engine had failed, and failed to follow approved crew procedures for an engine failure, for a single-engine approach and go-around, and for stall recovery.
Photo of 1994 American Eagle Flight 3379 Jetstream 3100 accident
As a result of this Jetstream accident, and at the request of the FAA, the AIA and European Association of Aerospace Industries (AECMA) formed a task force to study the related issue, and in 1998, released a report titled "Propulsion System Malfunction Plus Inappropriate Crew Response (PSM+ICR)". The report concluded that the causal factors included misleading simulator programming in representing engine malfunctions, and lack of pilot training in recognition and appropriate response to engine malfunctions. In 2009, The FAA and Airline Transport Association (ATA), in response to the AIA/AECMA report, went on to develop "Turbofan Engine Malfunction Recognition and Response Final Report" to provide pilot training material and simulator upgrade data packages to address this shortfall. The complete 1998 AIA/AECMA study is available at the following link: (AIA/AECMA Study) (Note: This report is included in a digest from the Flight Safety Foundation which includes multiple reports. The subject report concludes on page 193 of the linked document).
The FAA/ATA training material included a 22 minute video titled "Engine Malfunctions - Recognition and Response" which may be viewed at the following link: (Turbofan Engine Malfunction Training Video). In 2002, The Turboprop Engine Malfunction Recognition and Response Working Group released a similar training video related specifically to turboprop powered airplanes. The video, titled "Turboprop Malfunction Recognition and Response is available at the following link: ( Turboprop Engine Malfunction Training Video).