Accident Board Findings

The Air Accidents Investigation Branch of the Civil Aviation Authority (AAIB) issued 51 findings addressing the airplane, the flight deck and cabin crews, each engine, airplane systems, ground impact, and accident survivability. The complete text of the findings and excerpted from the accident report are available at the following link: (AAIB Findings).

The AAIB cited the accident cause as:

"The cause of the accident was that the operating crew shut down engine No 2 after a fan blade had fractured on the No 1 engine. This engine subsequently suffered a major thrust loss due to secondary fan damage after power had been increased during final approach to land."

The following factors contributed to the incorrect response of the flight crew:

  1. The combination of heavy engine vibration, noise, shuddering and an associated smell of fire were outside their training and experience.
  2. They reacted to the initial engine problem prematurely and in a way that was contrary to their training.
  3. They did not assimilate the indications on the engine instrument display before they throttled back the No 2 engine.
  4. As the No 2 engine was throttled back, the noise and shuddering associated with the surging of the No 1 engine ceased, persuading them that they had correctly identified the defective engine.
  5. They were not informed of the flames which had emanated from the No 1 engine and which had been observed by many on board, including three cabin attendants in the aft cabin.

The complete text of the accident report is available at the following link: (Accident Report)

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