Precursors

  • The crew was not familiar with the design of the new vibration monitoring system. Their habit pattern transfer from older type designs led them to disregard critical, and reliable, information. The accident board noted, "The commander seems to have been aware of the less than satisfactory performance of the earlier types of vibration monitor, probably from his past experience on the McDonnell Douglas DC-9. His subsequent training by Boeing on the 737 did not draw his attention to the much improved performance of the newer AVM system, and he had not practiced an emergency in which the AVM indications were used as a visual cue to assist him in fault diagnosis."
  • The crew had not received simulator training on the 737-400 Engine Instrument System (EIS). When British Midland took delivery of their first EIS equipped aircraft, no EIS equipped flight simulator was available. According to investigators, "the first time that a pilot was likely to see abnormal indications on the EIS was in-flight in an aircraft with a failing engine."

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