Lessons Learned

Technical Related Lessons

Adherence to rigorous flight deck discipline and operational procedures, including completion of checklists, is essential components of effective Crew Resource Management (CRM). (Threat Category: Crew Resource Management)

  • The primary event in the accident sequence was the flight crew's misidentification of the No 2 engine as the failed engine, and its subsequent shutdown. The investigation cited the crew's premature reaction in a manner contrary to their training and failure to refer to available engine instrumentation as contributors to the accident. Also, following the fan blade failure, control was shifted from the first officer (who had been controlling the airplane) to the captain. The investigation concluded that this transfer of control may have caused a delay in both crew members being fully cognizant of the nature of the failure and aided in their incorrect decision making. Further, during the descent and while attempting to complete associated checklists, on numerous occasions the crew was interrupted by, and responded to, air traffic communications, and consequently did not complete an evaluation of their situation. A proper assessment of their flight situation may have resulted in discovering the true nature of the failure, and correction of the earlier error, avoiding of the accident.

Adding the 16g dynamic seat rule has dramatically upgraded passenger and crew protection from injury and enhanced their ability to safely evacuate airplanes in survivable accidents. (Threat Category: Cabin Safety/Hazardous Cargo)

  • During the investigation it was found that the installed 9g static seats were not adequate to protect the passengers and crew from injury during this survivable accident.

Flightcrew communications regarding airplane safety readiness should be open and effective. Each crewmember must clearly give and receive communication in such a way that the flight safety decisions represent the best product of this open, two-way communication. (Threat Category: Crew Resource Management)

  • In this accident, the three cabin crew members had observed flames coming from the number 1 engine, but had not communicated this information to the flight deck crew. In a fully functional crew resource management (CRM) environment safety related information from passengers or other crew members should not be discouraged. Cabin crew members should be considered as a CRM resource, and within operational protocols (such as communicating during emergency situations), be expected to identify a potential safety issue to the flight crew.

Common Theme Related Lessons

When faced with an emergency situation, reference to all available instrumentation can be critical in determining, and properly responding to, the nature of the emergency. (Common Theme: Human Error)

  • The first event in the accident sequence was the failure of a fan blade on the No 1 engine. The crew incorrectly identified the No 2 engine as the failed engine, and eventually shut it down. The investigation cited the crew's lack of reference to the engine instruments, in particular the Airborne Vibration Monitor (AVM) indications, in determining which engine had failed. The accident report stated that if the crew had properly referred to the AVM indications, the failed engine would most likely have been correctly identified and the accident averted.

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