Common Themes

Organizational Lapses

British-Midlands made a decision to introduce a new aircraft, with a reliable AVM system, and a new EIS system, and they did not offer their crews an appropriate level of training. The accident report states they were given classroom instruction on the new displays, but no opportunity to practice interpretation of these displays in a simulator.

Human Error

The investigation concluded that a direct cause of the accident was the crew's misidentification and subsequent shutdown of the incorrect engine. While the investigation identified a number of possible reasons for the misidentification, if the error had not occurred, the investigation concluded that the accident would have been prevented.

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