Prevailing Cultural / Organizational Factors

The accident report stated that it was apparent that the flight crew did not assimilate the indications on both vibration indicators. The report concludes that this may have been a result of their general experience and the experience of other flight crews of early generation engine vibration indicators, who viewed the engine vibration indicating systems as inaccurate and of inferior performance. The investigation concluded that if the crew had consulted the vibration indications, the failed engine could have been correctly identified and the accident could have perhaps been avoided.

Further, when British Midland Airways took delivery of their first EIS equipped aircraft, a one-day training course was provided to highlight the differences between EIS equipped aircraft and those not so equipped. An EIS-equipped training simulator was not available, so the investigation concluded that the first time a flight crew was likely to see abnormal indications on an EIS would have been in flight in an aircraft with a failing engine.

Finally, the accident report stated that the performance of a flight crew in an emergency situation is largely a product of their training. In the simulator, the majority, if not all, engine problems result from the shut down of the problem engine. This reinforces the idea that all in-flight situations involving anomalous engine behavior should also result in an engine shutdown. The investigation concluded that it was not surprising that, since an engine shutdown was a normally trained and practiced event, that shutting down an engine in this case was a result.

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