Lessons Learned

Technical Related Lessons

The post crash safety provided by 9g static seats was demonstrated to be inadequate during this survivable accident. (Threat Category: Cabin Safety/Hazardous Cargo)

  • The investigation determined that this accident was survivable, and that the majority of injuries and fatalities was due to the failure of the seat structures. Had the seats been more structurally capable, and able to absorb the loads imparted by the impact, and associated deformation, the investigation concluded that the number of injuries and fatalities would have been substantially reduced.

Maintaining an environment of open, clear, and accurate communication among crew members, and between flight crews and air traffic controllers is essential for proper decision making, especially in an emergency situation. (Threat Category: Crew Resource Management)

  • The flight crew was aware that their fuel state was becoming increasingly critical as the flight progressed, and was frequently delayed due to weather induced holds. The captain repeatedly requested that the first officer inform ATC that the situation had become an emergency, but the first officer did not properly convey the urgency of the situation to ATC, and did not declare an emergency. As a result, ATC was not aware of the deteriorating situation onboard flight 52. Had an emergency been declared, following the go-around, rather than direct the flight back out to a sequenced approach position, ATC would have provided expedited handling, and given the flight priority for landing, which might have prevented the accident.

Common Theme Related Lessons

The safety provided by passenger accommodations and cabin equipment should be commensurate with the associated threat levels to which they will be exposed. (Common Theme: Flawed Assumptions)

  • It was determined by the investigation that though this accident was survivable, the failure of the seats and other cabin accommodations contributed to the high level of injuries and fatalities. The cabin accommodations were required to sustain a 9g static load, which was exceeded during this crash. Post accident investigations, and information gathered from this, and other accidents, led to the adoption of a 16g dynamic seat standard which has resulted in a substantial reduction in the ratio of injuries and fatalities in similar accidents.

Back to top