British Airways Flight 38
Encyclopedia
British Airways
Flight 38 (call sign Speedbird
38) was a scheduled flight from Beijing Capital International Airport
which crash landed just short of the runway at its destination, London Heathrow Airport
, on 17 January 2008 after an 8100 km (4,373.7 nmi; 5,033.1 mi) flight. There were no fatalities, but 47 people sustained injuries. The 150-tonne
aircraft was the first Boeing 777 to be written off in the model's 12-year history.
The cause was determined to have been ice crystals in the fuel clogging the fuel-oil heat exchanger (FOHE) of each engine. This restricted fuel flow to the engines as thrust was demanded during the final approach to Heathrow. Boeing identified the problem as specific to the Rolls-Royce engine fuel-oil heat exchanger
s, and Rolls-Royce has subsequently developed a modification to its FOHE; the European Aviation Safety Agency (EASA)
mandated that all affected aircraft were to be fitted with the modification before 1 January 2011. Boeing 777 aircraft powered by GE
or Pratt & Whitney
engines were not affected by the problem.
The Trent 800
engines aboard Boeing 777-236ER
aircraft (manufacturer's serial number 30314, line number 342) repeatedly failed to respond to a demand for increased thrust from both autothrottle
and from manual intervention at 720 feet (219.5 m) and 2 miles (3.2 km) from touchdown. In attempting to maintain the instrument landing system
(ILS) glide slope, the autopilot
sacrificed speed, reducing airspeed to 108 knots at 200 feet (61 m). The plane passed approximately 6 metres (19.7 ft) above passing cars on the A30
and the airport's Southern Perimeter road. It also passed near a car which had just dropped off the then British Prime Minister
, Gordon Brown
. The captain declared an emergency to the control tower 3 seconds before landing.
The autopilot disconnected at 175 feet (53.3 m) and the aircraft landed on the grass approximately 1000 feet (304.8 m) short of runway
27L. During the impact and short ground roll, the nose gear collapsed, the right main gear separated from the aircraft penetrating the central fuel tank and cabin space, and the left main gear was pushed up through the wing. The aircraft came to rest on the threshold markings at the start of the runway. A significant amount of fuel leaked, but there was no fire. Four crew members and eight passengers received minor injuries, and one passenger received serious injury – concussion and a broken leg.
, and was ruled out by the findings of the February Special Bulletin.
One theory was a failure of the software or electronics that controls the engines. A story in The Guardian
newspaper on 19 January 2008 quoted an unnamed source as stating that an automated alarm that should have alerted the pilots to the drop in engine power failed to actuate. A failure in the electronic system of the 777 aircraft was put forward as a possible culprit of the accident. According to a news report, an electronic glitch in the computerised engine-control systems may have disrupted the connection between automated and manual controls and the two jet engines. However, this was ruled out by the findings of the Special Bulletin. Speculation that radio interference from the Prime Minister's motorcade was responsible for the accident was also eliminated as a cause.
The second area of speculation, later confirmed as the cause in the official report, centred on the fuel supply. Under a fuel starvation
scenario, fuel was available but could not reach the engines. Water or debris in the fuel tanks could have cut off the engines from their supply, resulting in power loss. It was unclear, however, whether a fuel supply issue would have produced simultaneous engine failures or more likely would have produced symptoms in one engine before the other. However, according to the 24 January update, the engines lost power eight seconds apart—the right engine approximately three seconds after more power was requested, and the left engine eight seconds later. Accumulation of ice in the fuel tanks, clogging fuel supply lines in the final stages of the flight, was the subject of closer scrutiny, and while initially ruled out (as both engines were still producing above-idle but significantly diminished thrust, according to a report), this was, at the time of the 24 January update, being investigated as a possible cause.
David Learmount of Flight International
speculated that to land in just 350–400 metres, the aircraft must have been near stalling
when it touched down. Dr. Thurai Rahulan and Dr. Guy Gratton, both academics, speculated that the weather conditions made wind shear
a possible cause. The METAR
in force at the time indicated that the wind was forecast to gust according to ICAO
criteria for wind reporting, but was not gusting at the time and wind shear had not been reported. The possibility of a bird strike
was raised, but there were no sightings or radar reports of birds. Consequently, speculation had focused on electronics and fuel supply issues. In response to speculation that the cause of the accident was ice in the centre fuel tank, United Airlines
and American Airlines
took precautionary steps to ensure the quality of the fuel used in their aircraft.
stated that three fast response cars, nine ambulances and several officers were sent to the scene to assess the casualties. Those injured were taken to the nearby Hillingdon hospital
.
Soon after the crash, the Civil Aviation Authority (CAA)
announced that they were aware of the incident and that the "incident will be investigated by the Air Accidents Investigation Branch of the Department for Transport and the CAA is offering assistance to all organisations involved." Initial comment from David Learmount, a Flight International
analyst, was that "The aircraft had either a total or severe power loss and this occurred very late in the final approach because the pilot did not have time to tell air traffic control or passengers."
Willie Walsh, the British Airways Chief Executive released a statement praising the actions of the "flight and cabin crew [who] did a magnificent job and safely evacuated all of the 136 passengers. The captain of the aircraft is one of our most experienced and has been flying with us for nearly 20 years. Our crew are trained to deal with these situations." He also praised the fire, ambulance and police services.
BAA Limited:
During a press conference the day after the accident, Captain
Peter Burkill said that he would not be publicly commenting on the cause of the incident while the Air Accident Investigation Branch (AAIB) investigation was in progress. He revealed that Senior First Officer John Coward was flying the aircraft at the time and that another First Officer was also present, later identified as Conor Magenis.
John Coward was more forthcoming in a later interview, stating: "As the final approach started I became aware that there was no power ... Suddenly there was nothing from any of the engines, and the plane started to glide."
, Luton
or Stansted
, and Heathrow Airport received dispensation from the Department of Transport to operate some night flights. On the following day (18 January) a total of 113 short haul flights were cancelled due to crews and aircraft being out of position.
On the afternoon of 20 January 2008, the aircraft was removed from its resting place with two cranes lifting it onto wheeled platforms.
Captain Burkill and Senior First Officer Coward were grounded for a month following the crash while they were assessed for posttraumatic stress disorder. Five months after the accident, Captain Burkill flew again taking charge of a flight to Montreal, Canada. However, he remained "haunted" by the incident, and took voluntary redundancy from British Airways in August 2009. In September 2010, it was announced that Burkill was to rejoin British Airways in November 2010. Burkill said "I am delighted that the discussions with British Airways, have come to a mutually, happy conclusion. In my opinion British Airways is the pinnacle of any pilot's career and it is my honour and privilege to be returning to an airline that I joined as a young man."
Although it is a common practice that airlines discontinue a flight number after a crash, British Airways continues to use the Flight 38 designation on its Beijing to London (Heathrow) route. It now uses a 747 instead of a 777.
. Captain Burkill subsequently established a blog and wrote a book, "Thirty Seconds to Impact" that denounced BA's treatment of the situation following the crash.
(AAIB) investigated the accident, with the U.S. National Transportation Safety Board
(NTSB), Boeing
and Rolls-Royce
also participating. The investigation took two years to complete. A number of preliminary reports and safety recommendations were issued during the course of the investigation, and the AAIB published its final report on 9 February 2010.
The report noted evidence that cavitation
had taken place in both high pressure fuel pumps, which could be indicative of a restriction in the fuel supply or excessive aeration of the fuel, although the manufacturer assessed both pumps as still being able to deliver full fuel flow. The report noted the aircraft had flown through air that was unusually cold (but not exceptionally so), and concluded that the temperature had not been low enough to freeze the fuel. Tests are continuing in an attempt to replicate the damage seen in the fuel pumps and to match this to the data recorded on the flight. A comprehensive examination and analysis is to be conducted on the entire aircraft and engine fuel system including modelling fuel flows taking account of environmental and aerodynamic effects.
The report went on to note that the fire extinguisher handles had been manually deployed by the crew before the fuel shut-off switches. The fire extinguisher handles also have the effect of cutting off power to the fuel switches, meaning that the fuel may continue to flow – a potentially dangerous situation. The report restated a previous Boeing Service Bulletin giving procedural advice that fuel switches should be operated before fire handles. It went on: "This was not causal to the accident but could have had serious consequences in the event of a fire during the evacuation."
Indeed, the need to issue Safety Recommendation 2008-009, affecting all 777 airframes which had yet to incorporate the Boeing Service Bulletin (SB 777-28-0025) – as was the case with G-YMMM – was given as the main reason for issuing this special bulletin, well before the accident investigation itself was complete.
both engines was the result of a reduced fuel flow and all engine parameters after the thrust reduction were consistent with this." The report confirmed that the fuel was of good quality and had a freezing point below the coldest temperatures encountered, appearing to rule out fuel freezing as a cause. As in the aforementioned February bulletin, the report noted cavitation damage to the high pressure fuel pumps of both engines, indicative of abnormally low pressure at the pump inlets. After ruling out fuel freezing or contamination, the investigation now focuses on what caused the low pressure at the pump inlets. "Restrictions in the fuel system between the aircraft fuel tanks and each of the engine HP pumps, resulting in reduced fuel flows, is suspected." The fuel delivery system was being investigated at Boeing, and the engines at manufacturer Rolls Royce
in Derby
.
The Bulletin specifically ruled out certain other possible causes, stating: "There is no evidence of a wake vortex encounter, a bird strike or core engine icing. There is no evidence of any anomalous behaviour of any of the aircraft or engine systems that suggests electromagnetic interference."
The report detailed the extensive testing performed in an effort to replicate the problem suffered by G-YMMM. This included creating a mock-up of G-YMMM's fuel delivery system, to which water was added to study its freezing properties. After a battery of tests, the AAIB had not yet succeeded in reproducing the suspected icing behaviour, and was undertaking further investigation. Nevertheless, the AAIB believed its testing showed that fuel flow was restricted on G-YMMM and that frozen water in the jet fuel could have caused the restriction, ruling out alternative hypotheses such as a failure of the aircraft's FADEC
. The hypothesis favoured in the report was that ice had accreted somewhere downstream of the boost pumps in the wing fuel tanks and upstream of the engine-mounted fuel pumps. Either enough ice had accumulated to cause a blockage at a single point, or ice throughout the fuel lines had become dislodged as fuel flow increased during the landing approach, and the dislodged ice had then formed a blockage somewhere downstream.
Because temperatures in flight had not dropped below the 777's designed operating parameters, the Air Accidents Investigations Branch (AAIB)
recommended Boeing and Rolls-Royce take interim measures on Trent 800
-powered 777s to reduce the risk of ice restricting fuel delivery.
The report's finding resulted in three safety recommendations:
The report acknowledged that a redesign of the fuel system would not be practical in the near-term, and suggested two ways to lower the risk of recurrence. One was to use a fuel additive (FSII) that prevents water ice from forming down to −40 °C. Western air forces have used FSII for decades, and although it is not widely used in commercial aviation, it is nonetheless approved for the 777. The report also suggested that, because low fuel flows are conducive to ice formation, airlines could make operational changes to lessen the risk of a blockage forming shortly before landing.
Boeing revised the 777 operating procedures to keep such blockages from forming, and revised the procedure to be followed in the event of power loss to take into account the possibility that ice accumulation was the cause.
The AAIB also studied the crashworthiness of the aircraft during the accident sequence. It observed that the main attachment point for the main landing gear
(MLG) was the rear spar of the aircraft's wing; because this spar also formed the rear wall of the main fuel tanks, the crash landing caused the tanks to rupture. It was recommended that Boeing redesign the landing gear attachment to reduce the likelihood of fuel loss in similar circumstances. In all, eighteen recommendations were made as a result of the investigation.
On 26 November 2008, Delta Air Lines
Flight 18 from Shanghai to Atlanta experienced an "uncommanded rollback" of one engine while in cruise at 39,000 feet. The crew followed manual recovery procedures and the flight continued without incident. One of the U.S. NTSB investigators who worked on the BA Flight 38 investigation has been making the inquiry into this incident, and any similarity between the two incidents. The NTSB preliminary report is available.
In early 2009, Boeing sent an update to aircraft operators, linking the British Airways and Delta Air Lines "uncommanded rollback" incidents, and identifying the problem as specific to the Rolls-Royce engine oil-fuel flow heat exchanger
s. Originally, it was thought that other aircraft were not affected by the problem. However, in March 2009, another similar incident happened with an Airbus A330 powered by a Trent series 700 engine.
The enquiries resulted in a stronger recommendation from Boeing in February 2009 to avoid icing in fuel lines in extremely cold conditions.
On 11 March 2009, the National Transportation Safety Board
issued urgent safety recommendation SB-09-11 calling for the redesign of the fuel/oil heat exchangers used on Rolls-Royce Trent 800 Series engines. A build-up of ice from water naturally occurring in the fuel had caused a restriction of the flow of fuel to the engines of G-YMMM. Rolls-Royce have already started on redesigning the component, with an in-service date of March 2010 at the latest. All affected engines will be fitted with the redesigned component within six months of its certification. In May 2010, the Airworthiness Directive was extended to cover the Trent 500 and 700 series engines as well.
, in the United States. It is reported that each of the ten plaintiffs could receive up to US$1,000,000 (£
595,433 at the time) compensation. Boeing is reportedly trying to have the case heard at the High Court in London. The lawsuit alleges that the design of the aircraft was "defective and unreasonably dangerous", that Boeing "breached their duty of care" and also breached their "warranties of merchantability and fitness".
show Mayday
(known as Air Emergency in the US, Mayday in Ireland and Canada, and Air Crash Investigation in the UK and the rest of world). The episode is entitled "Heathrow Crash Landing".
British Airways
British Airways is the flag carrier airline of the United Kingdom, based in Waterside, near its main hub at London Heathrow Airport. British Airways is the largest airline in the UK based on fleet size, international flights and international destinations...
Flight 38 (call sign Speedbird
Speedbird
Speedbird is a call sign used by British Airways during air traffic control procedures, as well as the name for the stylised Imperial Airways and later, British Overseas Airways Corporation emblem.-History:...
38) was a scheduled flight from Beijing Capital International Airport
Beijing Capital International Airport
Beijing Capital International Airport, is the main international airport serving Beijing, China. It is located northeast of Beijing's city center in an enclave of Chaoyang District that is surrounded by rural Shunyi District. The airport is owned and operated by the Beijing Capital...
which crash landed just short of the runway at its destination, London Heathrow Airport
London Heathrow Airport
London Heathrow Airport or Heathrow , in the London Borough of Hillingdon, is the busiest airport in the United Kingdom and the third busiest airport in the world in terms of total passenger traffic, handling more international passengers than any other airport around the globe...
, on 17 January 2008 after an 8100 km (4,373.7 nmi; 5,033.1 mi) flight. There were no fatalities, but 47 people sustained injuries. The 150-tonne
Tonne
The tonne, known as the metric ton in the US , often put pleonastically as "metric tonne" to avoid confusion with ton, is a metric system unit of mass equal to 1000 kilograms. The tonne is not an International System of Units unit, but is accepted for use with the SI...
aircraft was the first Boeing 777 to be written off in the model's 12-year history.
The cause was determined to have been ice crystals in the fuel clogging the fuel-oil heat exchanger (FOHE) of each engine. This restricted fuel flow to the engines as thrust was demanded during the final approach to Heathrow. Boeing identified the problem as specific to the Rolls-Royce engine fuel-oil heat exchanger
Heat exchanger
A heat exchanger is a piece of equipment built for efficient heat transfer from one medium to another. The media may be separated by a solid wall, so that they never mix, or they may be in direct contact...
s, and Rolls-Royce has subsequently developed a modification to its FOHE; the European Aviation Safety Agency (EASA)
European Aviation Safety Agency
The European Aviation Safety Agency is an agency of the European Union with offices in Cologne, Germany, which has been given regulatory and executive tasks in the field of civilian aviation safety. It was created on 15 July 2002, and it reached full functionality in 2008, taking over functions...
mandated that all affected aircraft were to be fitted with the modification before 1 January 2011. Boeing 777 aircraft powered by GE
General Electric GE90
General Electric GE90 is a family of high-bypass turbofan aircraft engines built by GE Aviation for the Boeing 777, with thrust ratings ranging from 74,000 to 115,000 lbf . It was first introduced in November 1995 on British Airways' 777s, and is available only on the 777...
or Pratt & Whitney
Pratt & Whitney PW4000
|-See also:-External links:* * *...
engines were not affected by the problem.
Accident
Rolls-Royce Trent 800
|-See also:-External links:*...
engines aboard Boeing 777-236ER
Boeing 777
The Boeing 777 is a long-range, wide-body twin-engine jet airliner manufactured by Boeing Commercial Airplanes. It is the world's largest twinjet and is commonly referred to as the "Triple Seven". The aircraft has seating for over 300 passengers and has a range from , depending on model...
aircraft (manufacturer's serial number 30314, line number 342) repeatedly failed to respond to a demand for increased thrust from both autothrottle
Autothrottle
An autothrottle allows a pilot to control the power setting of an aircraft's engines by specifying a desired flight characteristic, rather than manually controlling fuel flow...
and from manual intervention at 720 feet (219.5 m) and 2 miles (3.2 km) from touchdown. In attempting to maintain the instrument landing system
Instrument Landing System
An instrument landing system is a ground-based instrument approach system that provides precision guidance to an aircraft approaching and landing on a runway, using a combination of radio signals and, in many cases, high-intensity lighting arrays to enable a safe landing during instrument...
(ILS) glide slope, the autopilot
Autopilot
An autopilot is a mechanical, electrical, or hydraulic system used to guide a vehicle without assistance from a human being. An autopilot can refer specifically to aircraft, self-steering gear for boats, or auto guidance of space craft and missiles...
sacrificed speed, reducing airspeed to 108 knots at 200 feet (61 m). The plane passed approximately 6 metres (19.7 ft) above passing cars on the A30
A30 road
The 284 miles A30 road from London to Land's End, historically known as the Great South West Road used to provide the most direct route from London to the south west; more recently the M3 motorway and A303 road performs this function for much of the route and only parts of A30 now retain trunk...
and the airport's Southern Perimeter road. It also passed near a car which had just dropped off the then British Prime Minister
Prime Minister of the United Kingdom
The Prime Minister of the United Kingdom of Great Britain and Northern Ireland is the Head of Her Majesty's Government in the United Kingdom. The Prime Minister and Cabinet are collectively accountable for their policies and actions to the Sovereign, to Parliament, to their political party and...
, Gordon Brown
Gordon Brown
James Gordon Brown is a British Labour Party politician who was the Prime Minister of the United Kingdom and Leader of the Labour Party from 2007 until 2010. He previously served as Chancellor of the Exchequer in the Labour Government from 1997 to 2007...
. The captain declared an emergency to the control tower 3 seconds before landing.
The autopilot disconnected at 175 feet (53.3 m) and the aircraft landed on the grass approximately 1000 feet (304.8 m) short of runway
Runway
According to ICAO a runway is a "defined rectangular area on a land aerodrome prepared for the landing and take-off of aircraft." Runways may be a man-made surface or a natural surface .- Orientation and dimensions :Runways are named by a number between 01 and 36, which is generally one tenth...
27L. During the impact and short ground roll, the nose gear collapsed, the right main gear separated from the aircraft penetrating the central fuel tank and cabin space, and the left main gear was pushed up through the wing. The aircraft came to rest on the threshold markings at the start of the runway. A significant amount of fuel leaked, but there was no fire. Four crew members and eight passengers received minor injuries, and one passenger received serious injury – concussion and a broken leg.
Speculation
Because both engines failed to produce increased power when demanded, mechanical engine failure was not regarded as a likely cause given the very low probability of a simultaneous dual engine failureTurbine engine failure
A turbine engine failure refers to an incident wherein a turbine engine in an aircraft unexpectedly stops producing power because of a part malfunction, in the absence of circumstances such as fuel exhaustion.-Nature of failures:...
, and was ruled out by the findings of the February Special Bulletin.
The Guardian
The Guardian, formerly known as The Manchester Guardian , is a British national daily newspaper in the Berliner format...
newspaper on 19 January 2008 quoted an unnamed source as stating that an automated alarm that should have alerted the pilots to the drop in engine power failed to actuate. A failure in the electronic system of the 777 aircraft was put forward as a possible culprit of the accident. According to a news report, an electronic glitch in the computerised engine-control systems may have disrupted the connection between automated and manual controls and the two jet engines. However, this was ruled out by the findings of the Special Bulletin. Speculation that radio interference from the Prime Minister's motorcade was responsible for the accident was also eliminated as a cause.
The second area of speculation, later confirmed as the cause in the official report, centred on the fuel supply. Under a fuel starvation
Fuel Starvation
Fuel starvation and fuel exhaustion are problems that can affect internal combustion engines fuelled by either diesel, kerosene, petroleum or any other combustible liquid or gas. If no fuel is available for an engine to burn, it cannot function...
scenario, fuel was available but could not reach the engines. Water or debris in the fuel tanks could have cut off the engines from their supply, resulting in power loss. It was unclear, however, whether a fuel supply issue would have produced simultaneous engine failures or more likely would have produced symptoms in one engine before the other. However, according to the 24 January update, the engines lost power eight seconds apart—the right engine approximately three seconds after more power was requested, and the left engine eight seconds later. Accumulation of ice in the fuel tanks, clogging fuel supply lines in the final stages of the flight, was the subject of closer scrutiny, and while initially ruled out (as both engines were still producing above-idle but significantly diminished thrust, according to a report), this was, at the time of the 24 January update, being investigated as a possible cause.
David Learmount of Flight International
Flight International
Flight International is a global aerospace weekly publication produced in the UK. Founded in 1909, it is the world's oldest continuously published aviation news magazine...
speculated that to land in just 350–400 metres, the aircraft must have been near stalling
Stall (flight)
In fluid dynamics, a stall is a reduction in the lift coefficient generated by a foil as angle of attack increases. This occurs when the critical angle of attack of the foil is exceeded...
when it touched down. Dr. Thurai Rahulan and Dr. Guy Gratton, both academics, speculated that the weather conditions made wind shear
Wind shear
Wind shear, sometimes referred to as windshear or wind gradient, is a difference in wind speed and direction over a relatively short distance in the atmosphere...
a possible cause. The METAR
METAR
METAR is a format for reporting weather information. A METAR weather report is predominantly used by pilots in fulfillment of a part of a pre-flight weather briefing, and by meteorologists, who use aggregated METAR information to assist in weather forecasting....
in force at the time indicated that the wind was forecast to gust according to ICAO
International Civil Aviation Organization
The International Civil Aviation Organization , pronounced , , is a specialized agency of the United Nations. It codifies the principles and techniques of international air navigation and fosters the planning and development of international air transport to ensure safe and orderly growth...
criteria for wind reporting, but was not gusting at the time and wind shear had not been reported. The possibility of a bird strike
Bird strike
A bird strike—sometimes called birdstrike, avian ingestion , bird hit, or BASH —is a collision between an airborne animal and a man-made vehicle, especially aircraft...
was raised, but there were no sightings or radar reports of birds. Consequently, speculation had focused on electronics and fuel supply issues. In response to speculation that the cause of the accident was ice in the centre fuel tank, United Airlines
United Airlines
United Air Lines, Inc., is the world's largest airline with 86,852 employees United Air Lines, Inc., is the world's largest airline with 86,852 employees United Air Lines, Inc., is the world's largest airline with 86,852 employees (which includes the entire holding company United Continental...
and American Airlines
American Airlines
American Airlines, Inc. is the world's fourth-largest airline in passenger miles transported and operating revenues. American Airlines is a subsidiary of the AMR Corporation and is headquartered in Fort Worth, Texas adjacent to its largest hub at Dallas/Fort Worth International Airport...
took precautionary steps to ensure the quality of the fuel used in their aircraft.
Initial response
The London Ambulance ServiceLondon Ambulance Service
The London Ambulance Service NHS Trust is the largest "free at the point of contact" emergency ambulance service in the world. It responds to medical emergencies in Greater London, England, with the ambulances and other response vehicles and over 5,000 staff at its disposal.It is one of 12...
stated that three fast response cars, nine ambulances and several officers were sent to the scene to assess the casualties. Those injured were taken to the nearby Hillingdon hospital
Hillingdon Hospital
Hillingdon Hospital is an NHS hospital, located in Pield Heath Road, Hillingdon, Greater London. It is a general hospital serving the local area, providing a wide variety of services including Accident and Emergency , In-patients, Day Surgery and Outpatient Clinics...
.
Soon after the crash, the Civil Aviation Authority (CAA)
United Kingdom Civil Aviation Authority
The Civil Aviation Authority is the public corporation which oversees and regulates all aspects of aviation in the United Kingdom. The CAA head office is located in the CAA House on Kingsway in Holborn, London Borough of Camden...
announced that they were aware of the incident and that the "incident will be investigated by the Air Accidents Investigation Branch of the Department for Transport and the CAA is offering assistance to all organisations involved." Initial comment from David Learmount, a Flight International
Flight International
Flight International is a global aerospace weekly publication produced in the UK. Founded in 1909, it is the world's oldest continuously published aviation news magazine...
analyst, was that "The aircraft had either a total or severe power loss and this occurred very late in the final approach because the pilot did not have time to tell air traffic control or passengers."
Willie Walsh, the British Airways Chief Executive released a statement praising the actions of the "flight and cabin crew [who] did a magnificent job and safely evacuated all of the 136 passengers. The captain of the aircraft is one of our most experienced and has been flying with us for nearly 20 years. Our crew are trained to deal with these situations." He also praised the fire, ambulance and police services.
BAA Limited:
During a press conference the day after the accident, Captain
Pilot in command
The pilot in command of an aircraft is the person aboard the aircraft who is ultimately responsible for its operation and safety during flight. This would be the "captain" in a typical two- or three-pilot flight crew, or "pilot" if there is only one certified and qualified pilot at the controls of...
Peter Burkill said that he would not be publicly commenting on the cause of the incident while the Air Accident Investigation Branch (AAIB) investigation was in progress. He revealed that Senior First Officer John Coward was flying the aircraft at the time and that another First Officer was also present, later identified as Conor Magenis.
John Coward was more forthcoming in a later interview, stating: "As the final approach started I became aware that there was no power ... Suddenly there was nothing from any of the engines, and the plane started to glide."
Aftermath
As a consequence of the emergency services deployment to the accident all flights were halted for a short time. When operations resumed, many long-haul outbound flights were either delayed or cancelled and all short haul flights were cancelled for the rest of the day. Some inbound flights were delayed and 24 flights were diverted to GatwickLondon Gatwick Airport
Gatwick Airport is located 3.1 miles north of the centre of Crawley, West Sussex, and south of Central London. Previously known as London Gatwick,In 2010, the name changed from London Gatwick Airport to Gatwick Airport...
, Luton
London Luton Airport
London Luton Airport is an international airport located east of the town centre in the Borough of Luton in Bedfordshire, England and is north of Central London. The airport is from Junction 10a of the M1 motorway...
or Stansted
London Stansted Airport
-Cargo:-Statistics:-Infrastructure:-Terminal and satellite buildings:Stansted is the newest passenger airport of all the main London airports. The terminal is an oblong glass building, and is separated in to three areas: Check-in concourse, arrivals and departures...
, and Heathrow Airport received dispensation from the Department of Transport to operate some night flights. On the following day (18 January) a total of 113 short haul flights were cancelled due to crews and aircraft being out of position.
On the afternoon of 20 January 2008, the aircraft was removed from its resting place with two cranes lifting it onto wheeled platforms.
Captain Burkill and Senior First Officer Coward were grounded for a month following the crash while they were assessed for posttraumatic stress disorder. Five months after the accident, Captain Burkill flew again taking charge of a flight to Montreal, Canada. However, he remained "haunted" by the incident, and took voluntary redundancy from British Airways in August 2009. In September 2010, it was announced that Burkill was to rejoin British Airways in November 2010. Burkill said "I am delighted that the discussions with British Airways, have come to a mutually, happy conclusion. In my opinion British Airways is the pinnacle of any pilot's career and it is my honour and privilege to be returning to an airline that I joined as a young man."
Although it is a common practice that airlines discontinue a flight number after a crash, British Airways continues to use the Flight 38 designation on its Beijing to London (Heathrow) route. It now uses a 747 instead of a 777.
Awards
All sixteen crew were awarded the BA Safety Medal for their performance during the accident. The medal is British Airways' highest honour. On 11 December 2008, the crew of BA038 were awarded the President's Award by the Royal Aeronautical SocietyRoyal Aeronautical Society
The Royal Aeronautical Society, also known as the RAeS, is a multidisciplinary professional institution dedicated to the global aerospace community.-Function:...
. Captain Burkill subsequently established a blog and wrote a book, "Thirty Seconds to Impact" that denounced BA's treatment of the situation following the crash.
Investigation
The Air Accidents Investigation BranchAir Accidents Investigation Branch
The Air Accidents Investigation Branch investigates air accidents in the United Kingdom. It is a branch of the Department for Transport and is based on the grounds of Farnborough Airport near Aldershot, Rushmoor, Hampshire.-History:...
(AAIB) investigated the accident, with the U.S. National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...
(NTSB), Boeing
Boeing
The Boeing Company is an American multinational aerospace and defense corporation, founded in 1916 by William E. Boeing in Seattle, Washington. Boeing has expanded over the years, merging with McDonnell Douglas in 1997. Boeing Corporate headquarters has been in Chicago, Illinois since 2001...
and Rolls-Royce
Rolls-Royce plc
Rolls-Royce Group plc is a global power systems company headquartered in the City of Westminster, London, United Kingdom. It is the world’s second-largest maker of aircraft engines , and also has major businesses in the marine propulsion and energy sectors. Through its defence-related activities...
also participating. The investigation took two years to complete. A number of preliminary reports and safety recommendations were issued during the course of the investigation, and the AAIB published its final report on 9 February 2010.
Initial report, 18 January 2008
The AAIB released an initial report on 18 January, which stated:Initial report update, 24 January 2008
An update was issued on 24 January:Special Bulletin, 18 February 2008
A further update, issued on 18 February, stated that there was "no evidence of a mechanical defect or ingestion of birds or ice", that there was "no evidence of fuel contamination or unusual levels of water content" within the fuel and that the recorded data indicated that there were "no anomalies in the major aircraft systems". Some small foreign bodies, however, were detected in the fuel tanks and these were to undergo further analysis.The report noted evidence that cavitation
Cavitation
Cavitation is the formation and then immediate implosion of cavities in a liquidi.e. small liquid-free zones that are the consequence of forces acting upon the liquid...
had taken place in both high pressure fuel pumps, which could be indicative of a restriction in the fuel supply or excessive aeration of the fuel, although the manufacturer assessed both pumps as still being able to deliver full fuel flow. The report noted the aircraft had flown through air that was unusually cold (but not exceptionally so), and concluded that the temperature had not been low enough to freeze the fuel. Tests are continuing in an attempt to replicate the damage seen in the fuel pumps and to match this to the data recorded on the flight. A comprehensive examination and analysis is to be conducted on the entire aircraft and engine fuel system including modelling fuel flows taking account of environmental and aerodynamic effects.
The report went on to note that the fire extinguisher handles had been manually deployed by the crew before the fuel shut-off switches. The fire extinguisher handles also have the effect of cutting off power to the fuel switches, meaning that the fuel may continue to flow – a potentially dangerous situation. The report restated a previous Boeing Service Bulletin giving procedural advice that fuel switches should be operated before fire handles. It went on: "This was not causal to the accident but could have had serious consequences in the event of a fire during the evacuation."
Indeed, the need to issue Safety Recommendation 2008-009, affecting all 777 airframes which had yet to incorporate the Boeing Service Bulletin (SB 777-28-0025) – as was the case with G-YMMM – was given as the main reason for issuing this special bulletin, well before the accident investigation itself was complete.
Special Bulletin, 12 May 2008
The AAIB issued a further bulletin on 12 May 2008 which confirmed that the investigation continued to focus on fuel delivery. It stated that "The reduction in thrust onboth engines was the result of a reduced fuel flow and all engine parameters after the thrust reduction were consistent with this." The report confirmed that the fuel was of good quality and had a freezing point below the coldest temperatures encountered, appearing to rule out fuel freezing as a cause. As in the aforementioned February bulletin, the report noted cavitation damage to the high pressure fuel pumps of both engines, indicative of abnormally low pressure at the pump inlets. After ruling out fuel freezing or contamination, the investigation now focuses on what caused the low pressure at the pump inlets. "Restrictions in the fuel system between the aircraft fuel tanks and each of the engine HP pumps, resulting in reduced fuel flows, is suspected." The fuel delivery system was being investigated at Boeing, and the engines at manufacturer Rolls Royce
Rolls-Royce plc
Rolls-Royce Group plc is a global power systems company headquartered in the City of Westminster, London, United Kingdom. It is the world’s second-largest maker of aircraft engines , and also has major businesses in the marine propulsion and energy sectors. Through its defence-related activities...
in Derby
Derby
Derby , is a city and unitary authority in the East Midlands region of England. It lies upon the banks of the River Derwent and is located in the south of the ceremonial county of Derbyshire. In the 2001 census, the population of the city was 233,700, whilst that of the Derby Urban Area was 229,407...
.
The Bulletin specifically ruled out certain other possible causes, stating: "There is no evidence of a wake vortex encounter, a bird strike or core engine icing. There is no evidence of any anomalous behaviour of any of the aircraft or engine systems that suggests electromagnetic interference."
British Airways internal investigation
An internal investigation into the accident was conducted by British Airways. The report concluded that the actions of the flight crew prevented a worse outcome than actually occurred. It also concluded that the emergency evacuation alarm was too quiet for some of the cabin crew to hear. This is also being investigated by the AAIB.Interim Report, 4 September 2008
The AAIB issued an interim report on 4 September. Offering a tentative conclusion, it stated:The report detailed the extensive testing performed in an effort to replicate the problem suffered by G-YMMM. This included creating a mock-up of G-YMMM's fuel delivery system, to which water was added to study its freezing properties. After a battery of tests, the AAIB had not yet succeeded in reproducing the suspected icing behaviour, and was undertaking further investigation. Nevertheless, the AAIB believed its testing showed that fuel flow was restricted on G-YMMM and that frozen water in the jet fuel could have caused the restriction, ruling out alternative hypotheses such as a failure of the aircraft's FADEC
FADEC
Full Authority Digital Engine Control is a system consisting of a digital computer, called an electronic engine controller or engine control unit , and its related accessories that control all aspects of aircraft engine performance...
. The hypothesis favoured in the report was that ice had accreted somewhere downstream of the boost pumps in the wing fuel tanks and upstream of the engine-mounted fuel pumps. Either enough ice had accumulated to cause a blockage at a single point, or ice throughout the fuel lines had become dislodged as fuel flow increased during the landing approach, and the dislodged ice had then formed a blockage somewhere downstream.
Because temperatures in flight had not dropped below the 777's designed operating parameters, the Air Accidents Investigations Branch (AAIB)
Air Accidents Investigation Branch
The Air Accidents Investigation Branch investigates air accidents in the United Kingdom. It is a branch of the Department for Transport and is based on the grounds of Farnborough Airport near Aldershot, Rushmoor, Hampshire.-History:...
recommended Boeing and Rolls-Royce take interim measures on Trent 800
Rolls-Royce Trent 800
|-See also:-External links:*...
-powered 777s to reduce the risk of ice restricting fuel delivery.
The report's finding resulted in three safety recommendations:
The report acknowledged that a redesign of the fuel system would not be practical in the near-term, and suggested two ways to lower the risk of recurrence. One was to use a fuel additive (FSII) that prevents water ice from forming down to −40 °C. Western air forces have used FSII for decades, and although it is not widely used in commercial aviation, it is nonetheless approved for the 777. The report also suggested that, because low fuel flows are conducive to ice formation, airlines could make operational changes to lessen the risk of a blockage forming shortly before landing.
Boeing revised the 777 operating procedures to keep such blockages from forming, and revised the procedure to be followed in the event of power loss to take into account the possibility that ice accumulation was the cause.
Final report, 9 February 2010
The AAIB issued a full report on 9 February 2010. It concluded :The AAIB also studied the crashworthiness of the aircraft during the accident sequence. It observed that the main attachment point for the main landing gear
Landing Gear
Landing Gear is Devin the Dude's fifth studio album. It was released on October 7, 2008. It was his first studio album since signing with the label Razor & Tie. It features a high-profile guest appearance from Snoop Dogg. As of October 30, 2008, the album has sold 18,906 copies.-Track...
(MLG) was the rear spar of the aircraft's wing; because this spar also formed the rear wall of the main fuel tanks, the crash landing caused the tanks to rupture. It was recommended that Boeing redesign the landing gear attachment to reduce the likelihood of fuel loss in similar circumstances. In all, eighteen recommendations were made as a result of the investigation.
Similar incidents
Delta Air Lines
Delta Air Lines, Inc. is a major airline based in the United States and headquartered in Atlanta, Georgia. The airline operates an extensive domestic and international network serving all continents except Antarctica. Delta and its subsidiaries operate over 4,000 flights every day...
Flight 18 from Shanghai to Atlanta experienced an "uncommanded rollback" of one engine while in cruise at 39,000 feet. The crew followed manual recovery procedures and the flight continued without incident. One of the U.S. NTSB investigators who worked on the BA Flight 38 investigation has been making the inquiry into this incident, and any similarity between the two incidents. The NTSB preliminary report is available.
In early 2009, Boeing sent an update to aircraft operators, linking the British Airways and Delta Air Lines "uncommanded rollback" incidents, and identifying the problem as specific to the Rolls-Royce engine oil-fuel flow heat exchanger
Heat exchanger
A heat exchanger is a piece of equipment built for efficient heat transfer from one medium to another. The media may be separated by a solid wall, so that they never mix, or they may be in direct contact...
s. Originally, it was thought that other aircraft were not affected by the problem. However, in March 2009, another similar incident happened with an Airbus A330 powered by a Trent series 700 engine.
The enquiries resulted in a stronger recommendation from Boeing in February 2009 to avoid icing in fuel lines in extremely cold conditions.
On 11 March 2009, the National Transportation Safety Board
National Transportation Safety Board
The National Transportation Safety Board is an independent U.S. government investigative agency responsible for civil transportation accident investigation. In this role, the NTSB investigates and reports on aviation accidents and incidents, certain types of highway crashes, ship and marine...
issued urgent safety recommendation SB-09-11 calling for the redesign of the fuel/oil heat exchangers used on Rolls-Royce Trent 800 Series engines. A build-up of ice from water naturally occurring in the fuel had caused a restriction of the flow of fuel to the engines of G-YMMM. Rolls-Royce have already started on redesigning the component, with an in-service date of March 2010 at the latest. All affected engines will be fitted with the redesigned component within six months of its certification. In May 2010, the Airworthiness Directive was extended to cover the Trent 500 and 700 series engines as well.
Lawsuit against Boeing
In November 2009, it was announced that 10 passengers were to sue Boeing for the incident. They have lodged a lawsuit with the Circuit Court of Cook County in IllinoisIllinois
Illinois is the fifth-most populous state of the United States of America, and is often noted for being a microcosm of the entire country. With Chicago in the northeast, small industrial cities and great agricultural productivity in central and northern Illinois, and natural resources like coal,...
, in the United States. It is reported that each of the ten plaintiffs could receive up to US$1,000,000 (£
Pound sterling
The pound sterling , commonly called the pound, is the official currency of the United Kingdom, its Crown Dependencies and the British Overseas Territories of South Georgia and the South Sandwich Islands, British Antarctic Territory and Tristan da Cunha. It is subdivided into 100 pence...
595,433 at the time) compensation. Boeing is reportedly trying to have the case heard at the High Court in London. The lawsuit alleges that the design of the aircraft was "defective and unreasonably dangerous", that Boeing "breached their duty of care" and also breached their "warranties of merchantability and fitness".
Dramatization
The story of the disaster was featured on the tenth season of Canadian National Geographic ChannelNational Geographic Channel
National Geographic Channel, also commercially abbreviated and trademarked as Nat Geo, is a subscription television channel that airs non-fiction television programs produced by the National Geographic Society. Like History and the Discovery Channel, the channel features documentaries with factual...
show Mayday
Mayday (TV series)
Mayday, also known as Air Crash Investigation in the United Kingdom, Australia and Asia and Air Emergency and Air Disasters in the United States, is a Canadian documentary television programme produced by Cineflix investigating air crashes, near-crashes and other disasters...
(known as Air Emergency in the US, Mayday in Ireland and Canada, and Air Crash Investigation in the UK and the rest of world). The episode is entitled "Heathrow Crash Landing".
See also
- List of notable accidents and incidents on commercial aircraft
- List of airline flights that required gliding
- Runway safety areaRunway safety areaA runway safety area or runway end safety area is defined as "the surface surrounding the runway prepared or suitable for reducing the risk of damage to airplanes in the event of an undershoot, overshoot, or excursion from the runway."Past standards called for the RSA to extend only 60m from the...
- Air safetyAir safetyAir safety is a term encompassing the theory, investigation and categorization of flight failures, and the prevention of such failures through regulation, education and training. It can also be applied in the context of campaigns that inform the public as to the safety of air travel.-United...
External links
- British Airways
- Audio interviews with Capt Peter Burkill on avweb.com: Part 1 (The Crash) and Part 2 (The Aftermath)
- August 2010 edition of Flaps PodcastFlaps PodcastFlaps Podcast is a British aviation podcast. Produced by BBC radio producer Mark Newman and presenter Elliott Webb, it discusses topics of interest to private and general aviation pilots....
: Interview with Captain Burkill, where he recounted his experience and its aftermath