British European Airways Flight 548
Encyclopedia
British European Airways Flight 548 (BE 548) was a Hawker Siddeley Trident 1C
airliner, registration
G-ARPI, operating as a British European Airways
(BEA) scheduled commercial passenger flight from London Heathrow Airport
to Brussels
, Belgium. At 16:11 Greenwich Mean Time
(GMT) on Sunday, 18 June 1972, less than three minutes after departing from Heathrow, the aircraft crashed near the town of Staines
, killing all 118 persons on board. The accident became known as the Staines disaster, and was the worst air disaster in Britain until the Pan Am Flight 103
bombing over Lockerbie
, Scotland in 1988.
The primary findings of the public inquiry
, based on data recovered from the flight data recorder
s, were that the crash resulted from a deep stall caused by the captain failing to maintain the correct airspeed
and configure the aircraft's high-lift device
s correctly, and that the crew failed to monitor the airspeed and aircraft configuration. Secondary factors included pilot incapacitation and the low experience level of the co-pilot. The process and findings of the inquiry were considered highly controversial among British pilots and the public.
Recommendations from the inquiry led to the mandatory installation of cockpit voice recorder
s in British-registered airliners. Another recommendation was for greater caution before allowing off-duty flight crew members to occupy flight deck seats.
On 18 June 2004 two memorials in Staines were dedicated to those who died in the accident.
The International Federation of Air Line Pilots' Associations
(IFALPA) had declared Monday 19 June 1972 (the day after the accident) as a worldwide protest strike
against aircraft hijacking
which had become commonplace in the early 1970s. Support was expected, but the British Air Line Pilots Association
(BALPA) nevertheless organised a confidential postal ballot
to ask its members at BEA whether or not they wanted to strike. Because of the impending strike action, air travellers had amended their plans to avoid disruption, and as a result Flight BE 548 was full, despite the service operating on a Sunday, traditionally a day of light travel.
BALPA was also in an industrial dispute with BEA, concerning issues of pay and working conditions. The dispute was highly controversial, with those in favour being mainly younger pilots, and those against mostly older pilots. A group of 22 BEA Trident co-pilots known as Supervisory First Officers (SFOs) were already on strike, citing their low status and high workload. To facilitate the further training of a number of newly-qualified co-pilots, SFOs were instructed to occupy only the third flight deck
seat of the Trident and to act in the capacity known as "P3", involving operating the aircraft’s systems and assisting the captain (known as "P1" on the BEA Trident fleet) and the co-pilot (known as "P2") who between them handled the aircraft. In other airlines and aircraft, the job of BEA Trident SFO/P3s was usually performed by flight engineer
s. As a result of being limited to the P3 role, BEA Trident SFOs/P3s were denied experience of aircraft handling, a measure which led to loss of pay, which they resented. In addition, their status led to a regular anomaly: experienced SFO/P3s could only assist while less-experienced co-pilots actually flew the aircraft.
A mere hour and a half before the departure of BE 548, its rostered captain, Stanley Key, was involved in a quarrel in the BEA crew room at Heathrow’s Queen’s Building with a First Officer named Flavell. The subject of Key's outburst was the threatened strike which Flavell supported and Key opposed. Both of Key's flight deck crew members on BE 548 witnessed the altercation, and another bystander described Key’s outburst as "the most violent argument he had ever heard". Shortly afterwards Key apologised to Flavell, and the matter seemed closed. Key’s robustly anti-strike views had won him enemies in the weeks before the accident, and graffiti
directed personally against him had appeared on the flight decks of BEA Tridents, including Papa India. The graffiti found on Papa India's P3 desk was analysed by a handwriting expert
during the investigation to determine who might have written it, but this could not be determined and the public inquiry members eventually dismissed it as irrelevant.
Series 1 short- to medium-range three-engined airliner
. This particular Trident was one of twenty-four de Havilland
DH.121s ordered by BEA in 1959, and with the constructor's number 2109 it was registered
to the corporation as G-ARPI in 1961. By the time of the aircraft's first flight on the 14 April 1964 the company had become Hawker Siddeley Aviation, and Papa India was delivered to BEA on 2 May 1964.
While technically advanced, the Trident (and other aircraft with a T-tail
arrangement) had potentially dangerous stalling characteristics. If its airspeed
was insufficient, and particularly if its high-lift device
s were not extended at the low speeds typical of climbing away after take-off
or of approaching to land, it could enter a deep stall (or "superstall") condition from which recovery was practically impossible.
The danger first came to light in a near-crash during a 1962 test flight when de Havilland
pilots Peter Bugge and Ron Clear were testing the Trident's stalling characteristics by pitching its nose progressively higher, thus reducing its airspeed: "After a critical angle of attack
was reached, the Trident began to sink tail-down in a deep stall." Eventually it entered a flat spin
, and a crash "looked inevitable", but luck saved the test crew. The incident resulted in the Trident being fitted with an automatic stall warning system known as a "stick shaker
", and a stall recovery system known as a "stick pusher
" which automatically pitched the aircraft down in order to build up speed if the crew failed to respond to the warning.
These systems were the subject of "one of the most comprehensive stall programmes on record", involving some 3,500 stalls being performed by Hawker Siddeley before the matter "was squared off to the satisfaction of ... the ARB" (Air Registration Board). The stall warning and recovery systems tended to over-react: of ten activations between the Trident entering service and June 1972, only half were genuine, although there had been no false in-flight activations. BEA Trident pilots were questioned informally by one captain, over half of them said that they would disable the protection systems on activation, rather than let them recover the aircraft to a safe attitude. Random checks carried out by the airline after the accident showed that this was not the case; 21 captains stated that they had witnessed their co-pilots react correctly to any stall warnings.
of Trident 1C, G-ARPY, on 3 June 1966 near Felthorpe
in Norfolk during a test flight, with the loss of all four pilots on board. In this accident the crew had deliberately switched off the stick shaker and stick pusher to perform their stall tests, and the probable cause was determined to be the crew's failure to take timely positive recovery action to counter an impending stall. The Confidential Human Factors Incident Reporting Programme (CHIRP), an experimental, voluntary, anonymous, and informal system of reporting hazardous air events introduced within BEA in the late 1960s, (later adopted by the Civil Aviation Authority and NASA
), brought to light two earlier near-accidents, the "Orly" and "Naples" incidents, that involved flight crew error in the first case and suspicion of the Trident’s control layout in the second.
shortly after take-off. This was a non-standard procedure, and shortly after he also retracted the leading edge droops
. This configuration of high-lift device
s at a low airspeed would have resulted in a deep stall, but fortunately the co-pilot noticed the error, increased airspeed and re-extended the droops, and the flight continued normally. The event became known as the "Paris Incident" or the "Orly Incident" among BEA staff.
Investigations into the event found no mechanical malfunction that could have caused the premature leading edge device retraction, and stated that the aircraft had "just about managed to stay flying". A possible design fault in the high-lift control interlock
s came under suspicion, although this was discounted during the investigation into the crash of Papa India. The event became known as the "Naples Incident" or the "Foxtrot Hotel Incident" (after the registration of the aircraft concerned) at BEA and was examined during the accident inquiry. The forward fuselage of this aircraft is preserved and on public display at the de Havilland Aircraft Heritage Centre
, London Colney
.
freight aircraft, G-AMAD, deviated from the runway on landing at Heathrow due to a control failure and struck G-ARPI and its neighbouring sister aircraft, G-ARPT, while they were parked unoccupied near Terminal 1, resulting in six fatalities from the freighter's eight occupants. G-ARPT was damaged beyond economic repair, but G-ARPI was repaired at a cost of £750,000 and had performed satisfactorily thereafter.
(GMT) from the official accident report.
Stanley Key as P1, Second Officer
Jeremy Keighley as P2 and Second Officer Simon Ticehurst as P3. The captain was 51 and had accumulated 15,000 flying hours experience, of which 4,000 were on Tridents. Keighley was 22 and had joined line flying a month and a half earlier, with 29 hours as P2. Ticehurst was 24 and had over 1,400 hours, including 750 hours on Tridents.
Among the passengers were 29 Americans, 29 Belgians, 28 Britons, 12 Irish, four South Africans and three Canadians. There was also one passenger from each of French West Africa, India, Jamaica, Latin America, Nigeria and Thailand. There were between 25 and 30 women passengers and several children on board.
At 15:36 flight dispatcher J Coleman presented the load sheet to Key whose request for engine start clearance was granted three minutes later. As the doors were about to close, Coleman asked Key to accommodate a BEA flight crew which had to collect a Merchantman
aircraft from Brussels. The additional weight of the three crew members necessitated the removal of a quantity of mail and freight from the Trident to ensure its total weight (less fuel)
did not exceed the permitted maximum of 41,730 kg. This was exceeded by 24 kg, but as there had been considerable fuel burnoff between startup and takeoff, the total aircraft weight (including fuel) was within the maximum permitted take-off weight.
The "dead-heading
" crew was led by Captain John Collins, an experienced former Trident First Officer, who was allocated the observer's seat on the flight deck. One seat, occupied by a baby, was freed by the mother holding it in her arms.
The doors closed at 15:58 and at 16:00 Key requested pushback
. At 16:03 BE 548 was cleared to taxi to the holding point adjacent to the start of Runway
27 Right. During taxi, at 16:06 the flight received its departure route clearance: a routing known as the "Dover One Standard Instrument Departure". This Standard Instrument Departure
involved taking-off to the west over the Instrument Landing System
localiser and middle marker beacon of the reciprocal Runway 09 Left, turning left to intercept the 145° bearing to the Epsom
Non-Directional Beacon
(NDB) (to be passed at 3000 feet (914.4 m) or more), and then proceeding to Dover
. Key advised the tower
that he was ready for take-off and was cleared to do so. He subsequently reported an unspecified technical problem and remained at the holding point for two minutes to resolve it.
At 16:08 Key again requested and received take-off clearance. A cross wind was blowing from 210°
at 17 knots (31 km/h). Conditions were turbulent, with driving rain and a low cloud base
of 1000 feet (304.8 m); broken cloud was also reported at 600 feet (182.9 m). At 16:08:30, BE 548 began its take-off run which lasted 44 seconds, the aircraft leaving the ground at an indicated airspeed
(IAS) of 145 knots (284.2 km/h). The safe climb speed (V2)
of 152 knots (297.9 km/h) was reached quickly, and the undercarriage
was retracted. After 19 seconds in the air the autopilot
was engaged at 355 feet (108.2 m) and 170 knots (333.2 km/h); the autopilot’s airspeed lock was engaged even though the actual required initial climb speed was 177 knots (346.9 km/h).
At 16:09:44 (74 seconds after the start of the take-off run), passing 690 feet (210.3 m), Key commenced the turn towards the Epsom NDB and reported that he was climbing as cleared and the flight entered cloud. At 16:10 (90 seconds), Key commenced a standard noise abatement
procedure which involved reducing engine power. As part of this, at 16:10:03 (93 seconds) he retracted the flaps from their take-off setting of 20°. Shortly afterwards, BE 548 reported passing 1500 feet (457.2 m) above ground level and was re-cleared to climb to 6000 feet (1,828.8 m) above sea level. During the turn, the airspeed decreased to 157 knots (307.7 km/h), 20 knots (39.2 km/h) below the target speed.
activated on the flight deck, followed at 16:10:26 hrs (116 seconds) by a stick shake and at 16:10:27hrs (117 seconds) by a stick push which disconnected the autopilot, in turn activating a loud autopilot disconnect warning horn that continued to sound for the remainder of the flight. Key levelled the wings but held the aircraft's nose up, which kept the angle of attack
high, further approaching a stall.
By 16:10:32 (122 seconds), the leading edge devices had stowed fully into the wing. The speed was 177 knots (346.9 km/h), and height above the ground was 1560 feet (475.5 m), with the aircraft still held into its usual climb attitude. Key continued to hold the nose-up attitude when there was a second stick shake and stick push in the following two seconds. A third stick push followed 127 seconds into the flight but no recovery was attempted. One second later, the stall warning and recovery system was overridden by a flight crew member.
At 16:10:39 (129 seconds), the aircraft had descended to 1275 feet (388.6 m) and accelerated to 193 knots (378.2 km/h) as a result of the stall recovery system having pitched the aircraft's nose down to increase airspeed. G-ARPI was in a 16° banked turn to the right, still on course to intercept its assigned route. Key pulled the nose up once more to reduce airspeed slightly, to the normal 'droops extended' climb speed of 177 knots (346.9 km/h), but this further stalled the aircraft.
At 16:10:43 (133 seconds), the Trident entered a deep stall. It was descending through 1200 feet (365.8 m), its nose was pitched up by 31°, and its airspeed had fallen below the minimum indication of 54 knots (105.8 km/h). At 16:10:55 (145 seconds) and 1000 feet (304.8 m), the Trident was descending at 4500 ft/min. Impact with the ground came at 16:11 precisely, 150 seconds after brake release.
The aircraft just cleared high-tension
overhead power lines and came to rest on a narrow strip of land surrounded by tall trees immediately south of the A30
road, and a short distance south of the King George VI Reservoir
near the town of Staines
.There was no fire on impact; however, one broke out during the rescue effort when cutting apparatus was used.
Air traffic controllers had not noticed the disappearance from radar
of BE 548, while the emergency services only became aware of the accident after 15 minutes had passed and did not know the precise circumstances of it for nearly an hour. First on the scene of the accident was a nurse who lived nearby, who had been alerted by the two boys, and an ambulance crew that happened to be driving past by chance. A male passenger who had survived the accident was discovered in the aircraft cabin, but died without recovering consciousness on arrival at Ashford
Hospital. A young girl was also found alive but died at the scene; there were no other survivors. Altogether, 30 ambulances and 25 fire engines attended the accident.
Sensation-seeking occupants of cars formed heavy traffic jams soon after, and were described by Minister of Aerospace Michael Heseltine
on BBC
Television that evening as "Ghouls, unfortunate ghouls". However the crash site was sufficiently inaccessible for the police to successfully control spectators, and contemporary reports that members of the public impeded rescue services by their presence near the site were dismissed during the subsequent inquiry.
A BEA Captain, Eric Pritchard, arrived at the accident scene shortly after the bodies had been removed, he noted the condition of the wreckage and drew his own early conclusions:
The accident became known as the Staines disaster, and was the worst air disaster in Britain prior to the Pan Am Flight 103
bombing over Lockerbie
, Scotland in 1988. The crash was also the first aviation disaster to occur in the United Kingdom involving the loss of more than 100 lives.
that he had directed a Court of Inquiry, an ad hoc tribunal popularly called a "public inquiry
", to investigate and report on the accident. Public inquiries bypassed the usual British practice whereby the Accidents Investigation Branch (AIB) investigated and reported on air crashes, and were held only in cases of acute public interest. On 14 July, the High Court
Judge Sir Geoffrey Lane
was appointed to preside over the inquiry as Commissioner.
The British aviation community was wary of public inquiries for several reasons. In such inquiries, AIB inspectors were on an equal footing with all other parties, and the ultimate reports were not drafted by them, but by the Commissioner and his or her Assessors. Proceedings were often adversarial, with counsel
for victims' families regularly attempting to secure positions for future litigation
, and deadlines were frequently imposed on investigators. Pressure of work caused by the Lane Inquiry was blamed for the death of a senior AIB inspector who committed suicide during the inquiry.
s were removed for immediate examination, and investigations at the site of the accident were completed within a week. The wreckage of Papa India was then removed to a hangar
at the Royal Aircraft Establishment
in Farnborough, Hampshire
, for partial re-assembly aimed at checking the integrity of its flight control systems. An inquest
was held into the 118 deaths, opening on 27 June 1972.
The pathologist
stated that Captain Key had a pre-existing heart condition, atherosclerosis
, and had suffered a potentially distressing arterial event caused by raised blood pressure typical of stress. (This event was popularly interpreted by the public as a heart attack.)
It had taken place "not more than two hours before the death and not less than about a minute" according to the pathologist's opinion given as evidence during the public inquiry. In other words, Key could have suffered it at any time between the row in the crewroom and 90 seconds after the start of the take-off run or the instant of commencing noise abatement procedures. The pathologist could not specify the degree of discomfort or incapacitation which Key might have felt. The Captain's medical state continued to be the subject of "conflicting views of medical experts" throughout the inquiry and beyond.
Hotel in London on 20 November 1972, and continued for 37 business days until 25 January 1973 despite expectations that it would end sooner. It was opened by Geoffrey Wilkinson of the AIB with a description of the accident, and counsel for the relatives of the crew members and passengers then presented the results of their private investigations. In particular, Lee Kreindler of the New York City Bar
presented claims and arguments which were considered tendentious and inadmissible by pilots and press reporters. They involved hypotheses
about the mental state of Captain Key, conjecture about his physical state (Kreindler highlighted disagreements between US and British cardiologists
) and allegations about BEA management. The allegations were delivered using tactics considered as "bordering on the unethical". The inquiry also conducted field inspections, flew in real Tridents and "flew" the BEA Trident simulator
as well as observing the Hawker Siddeley Trident control systems rig. Its members visited the reassembled wreckage of G-ARPI at Farnborough and were followed by the press throughout their movements. The bare facts being more-or-less uncovered soon after the event, the inquiry was frustrated by the absence on the accident aircraft of a cockpit voice recorder
.
The stall warning and stall recovery systems were at the centre of the inquiry, which examined in some detail their operation and why the flight crew might have overridden them. A three-way air pressure valve (part of the stall recovery system) was found to have been one-sixth of a turn out of position, and the locking wire
which secured it was missing. Calculations carried out by Hawker Siddeley determined that if the valve was in this position during the flight then the reduction in engine power for the noise abatement procedure may well have activated the warning light that indicated low air pressure in the system. The failure indications might have appeared just prior to take-off and could have accounted for the two-minute delay at the end of the runway.A captain who had flown Papa India on the morning of the accident flight noted no technical problems, and the public inquiry found that the position of the valve had no significant effect on the system.
paid tribute to the work done by Mr Justice Lane
, Sir Morien Morgan
and Captain Jessop for the work they had carried out during the inquiry into the accident.
The inquiry's findings as to the main causes of the accident, were that:
Underlying causes of the accident were also identified:
Recommendations included an urgent call for cockpit voice recorders and for closer cooperation between the Civil Aviation Authority and British airlines. Though the report covered the state of industrial relations at BEA, no mention was made of it in its conclusions, despite the feelings of observers that it intruded directly and comprehensively onto the flight deck of the stricken aircraft. BEA ceased to exist as a separate entity in 1974, when it and British Overseas Airways Corporation
merged to form British Airways
. A recommendation of the report that all British-registered civil passenger-carrying aircraft of more than 27000 kg (59,524.8 lb) all-up weight should be equipped with cockpit voice recorders resulted in their fitting becoming mandatory on larger British-registered airliners from 1973.
One issue treated as secondary at the inquiry was the presence on the flight deck observer's seat of Captain Collins. The Lane report recommended greater caution in allowing off-duty flight crew members to occupy flight deck seats, and aired speculation that Collins might have been distracting his colleagues. Sources close to the events of the time suggest that Collins played an altogether more positive role by attempting to lower the leading edge devices in the final seconds of the flight.
There were protests at the conduct of the inquiry by BALPA (which likened it to "a lawyers' picnic"), and by the Guild of Air Pilots and Air Navigators
which condemned the rules of evidence adopted and the adversarial nature of the proceedings. Observers also pointed to an unduly favourable disposition by the inquiry to Hawker Siddeley, manufacturer of the Trident, and to the makers of the aircraft's systems. Debate about the inquiry continued throughout 1973 and beyond.
The accident led to a much greater emphasis on crew resource management
training, a system of flight deck safety awareness that remains in use today.
. A referendum approving Ireland's entry
had been passed in May.
A group of 16 doctors and senior staff from the Royal London Homeopathic Hospital
were also on board the flight, and a memorial bench to them can be found close to Great Ormond Street Hospital in Queen Square.
.
The first is a stained glass window in St Mary's
church, Church Street. The second is a slightly more accessible area of reflection with seating on the Moormede estate, close to where the accident occurred. The memorial is in the park/play area near the end of Waters Drive in the Moormede Estate.
Similar accidents
Lists
Hawker Siddeley Trident
The Hawker Siddeley HS 121 Trident was a British short/medium-range three-engined jet airliner designed by de Havilland and built by Hawker Siddeley in the 1960s and 1970s...
airliner, registration
Aircraft registration
An aircraft registration is a unique alphanumeric string that identifies a civil aircraft, in similar fashion to a licence plate on an automobile...
G-ARPI, operating as a British European Airways
British European Airways
British European Airways or British European Airways Corporation was a British airline which existed from 1946 until 1974. The airline operated European and North African routes from airports around the United Kingdom...
(BEA) scheduled commercial passenger flight from 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...
to Brussels
Brussels Airport
Brussels Airport is an international airport northeast of Brussels, Belgium. The airport is partially in Zaventem and partially in the Diegem area of Machelen, both located in the Flemish Region of Belgium.Brussels Airport currently consists of 54 contact gates, and a total of 109 gates...
, Belgium. At 16:11 Greenwich Mean Time
Greenwich Mean Time
Greenwich Mean Time is a term originally referring to mean solar time at the Royal Observatory in Greenwich, London. It is arguably the same as Coordinated Universal Time and when this is viewed as a time zone the name Greenwich Mean Time is especially used by bodies connected with the United...
(GMT) on Sunday, 18 June 1972, less than three minutes after departing from Heathrow, the aircraft crashed near the town of Staines
Staines
Staines is a Thames-side town in the Spelthorne borough of Surrey and Greater London Urban Area, as well as the London Commuter Belt of South East England. It is a suburban development within the western bounds of the M25 motorway and located 17 miles west south-west of Charing Cross in...
, killing all 118 persons on board. The accident became known as the Staines disaster, and was the worst air disaster in Britain until the Pan Am Flight 103
Pan Am Flight 103
Pan Am Flight 103 was Pan American World Airways' third daily scheduled transatlantic flight from London Heathrow Airport to New York's John F. Kennedy International Airport...
bombing over Lockerbie
Lockerbie
Lockerbie is a town in the Dumfries and Galloway region of south-western Scotland. It lies approximately from Glasgow, and from the English border. It had a population of 4,009 at the 2001 census...
, Scotland in 1988.
The primary findings of the public inquiry
Public inquiry
A Tribunal of Inquiry is an official review of events or actions ordered by a government body in Common Law countries such as the United Kingdom, Ireland or Canada. Such a public inquiry differs from a Royal Commission in that a public inquiry accepts evidence and conducts its hearings in a more...
, based on data recovered from the flight data recorder
Flight data recorder
A flight data recorder is an electronic device employed to record any instructions sent to any electronic systems on an aircraft. It is a device used to record specific aircraft performance parameters...
s, were that the crash resulted from a deep stall caused by the captain failing to maintain the correct airspeed
Airspeed
Airspeed is the speed of an aircraft relative to the air. Among the common conventions for qualifying airspeed are: indicated airspeed , calibrated airspeed , true airspeed , equivalent airspeed and density airspeed....
and configure the aircraft's high-lift device
High-lift device
In aircraft design, high-lift devices are moving surfaces or stationary components intended to increase lift during certain flight conditions. They include common devices such as flaps and slats, as well as less common features such as leading edge extensions and blown flaps.-Purpose:Aircraft...
s correctly, and that the crew failed to monitor the airspeed and aircraft configuration. Secondary factors included pilot incapacitation and the low experience level of the co-pilot. The process and findings of the inquiry were considered highly controversial among British pilots and the public.
Recommendations from the inquiry led to the mandatory installation of cockpit voice recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...
s in British-registered airliners. Another recommendation was for greater caution before allowing off-duty flight crew members to occupy flight deck seats.
On 18 June 2004 two memorials in Staines were dedicated to those who died in the accident.
Industrial relations background
International Federation of Air Line Pilots' Associations
The International Federation of Air Line Pilots' Associations was created during a conference of pilots' associations held in London in April 1948 for the express purpose of providing a formal means for the airline pilots of the world to interact with the then newly formed UN body the...
(IFALPA) had declared Monday 19 June 1972 (the day after the accident) as a worldwide protest strike
Strike action
Strike action, also called labour strike, on strike, greve , or simply strike, is a work stoppage caused by the mass refusal of employees to work. A strike usually takes place in response to employee grievances. Strikes became important during the industrial revolution, when mass labour became...
against aircraft hijacking
Aircraft hijacking
Aircraft hijacking is the unlawful seizure of an aircraft by an individual or a group. In most cases, the pilot is forced to fly according to the orders of the hijackers. Occasionally, however, the hijackers have flown the aircraft themselves, such as the September 11 attacks of 2001...
which had become commonplace in the early 1970s. Support was expected, but the British Air Line Pilots Association
British Air Line Pilots Association
The British Air Line Pilots' Association represents well over 75% of all the fixed wing pilots and helicopter aircrew based in the UK - as well as many working overseas. The Association has a membership of over 10,000 professional flight crew, working in companies large and small...
(BALPA) nevertheless organised a confidential postal ballot
Postal voting
Postal voting describes the method of voting in an election whereby ballot papers are distributed or returned by post to electors, in contrast to electors voting in person at a polling station or electronically via an electronic voting system....
to ask its members at BEA whether or not they wanted to strike. Because of the impending strike action, air travellers had amended their plans to avoid disruption, and as a result Flight BE 548 was full, despite the service operating on a Sunday, traditionally a day of light travel.
BALPA was also in an industrial dispute with BEA, concerning issues of pay and working conditions. The dispute was highly controversial, with those in favour being mainly younger pilots, and those against mostly older pilots. A group of 22 BEA Trident co-pilots known as Supervisory First Officers (SFOs) were already on strike, citing their low status and high workload. To facilitate the further training of a number of newly-qualified co-pilots, SFOs were instructed to occupy only the third flight deck
Cockpit
A cockpit or flight deck is the area, usually near the front of an aircraft, from which a pilot controls the aircraft. Most modern cockpits are enclosed, except on some small aircraft, and cockpits on large airliners are also physically separated from the cabin...
seat of the Trident and to act in the capacity known as "P3", involving operating the aircraft’s systems and assisting the captain (known as "P1" on the BEA Trident fleet) and the co-pilot (known as "P2") who between them handled the aircraft. In other airlines and aircraft, the job of BEA Trident SFO/P3s was usually performed by flight engineer
Flight engineer
Flight engineers work in three types of aircraft: fixed-wing , rotary wing , and space flight .As airplanes became even larger requiring more engines and complex systems to operate, the workload on the two pilots became excessive during certain critical parts of the flight regime, notably takeoffs...
s. As a result of being limited to the P3 role, BEA Trident SFOs/P3s were denied experience of aircraft handling, a measure which led to loss of pay, which they resented. In addition, their status led to a regular anomaly: experienced SFO/P3s could only assist while less-experienced co-pilots actually flew the aircraft.
Captain Key's outburst
Tensions and hazards resulting from the positions in which BEA Trident SFOs and young co-pilots were placed came to a head shortly before the accident. On Thursday 15 June, a captain complained vociferously that the inexperienced co-pilot whom he had been assigned "would be useless in an emergency". Upset, the co-pilot committed a serious error on departure from Heathrow. The mistake was noted and remedied by the SFO, who later related the event to his colleagues as an example of avoidable danger. This event became known among BEA pilots as the "Dublin Incident".A mere hour and a half before the departure of BE 548, its rostered captain, Stanley Key, was involved in a quarrel in the BEA crew room at Heathrow’s Queen’s Building with a First Officer named Flavell. The subject of Key's outburst was the threatened strike which Flavell supported and Key opposed. Both of Key's flight deck crew members on BE 548 witnessed the altercation, and another bystander described Key’s outburst as "the most violent argument he had ever heard". Shortly afterwards Key apologised to Flavell, and the matter seemed closed. Key’s robustly anti-strike views had won him enemies in the weeks before the accident, and graffiti
Graffiti
Graffiti is the name for images or lettering scratched, scrawled, painted or marked in any manner on property....
directed personally against him had appeared on the flight decks of BEA Tridents, including Papa India. The graffiti found on Papa India's P3 desk was analysed by a handwriting expert
Calligraphy
Calligraphy is a type of visual art. It is often called the art of fancy lettering . A contemporary definition of calligraphic practice is "the art of giving form to signs in an expressive, harmonious and skillful manner"...
during the investigation to determine who might have written it, but this could not be determined and the public inquiry members eventually dismissed it as irrelevant.
Operational background
The aircraft operating Flight BE 548 was a Hawker Siddeley TridentHawker Siddeley Trident
The Hawker Siddeley HS 121 Trident was a British short/medium-range three-engined jet airliner designed by de Havilland and built by Hawker Siddeley in the 1960s and 1970s...
Series 1 short- to medium-range three-engined airliner
Airliner
An airliner is a large fixed-wing aircraft for transporting passengers and cargo. Such aircraft are operated by airlines. Although the definition of an airliner can vary from country to country, an airliner is typically defined as an aircraft intended for carrying multiple passengers in commercial...
. This particular Trident was one of twenty-four de Havilland
De Havilland
The de Havilland Aircraft Company was a British aviation manufacturer founded in 1920 when Airco, of which Geoffrey de Havilland had been chief designer, was sold to BSA by the owner George Holt Thomas. De Havilland then set up a company under his name in September of that year at Stag Lane...
DH.121s ordered by BEA in 1959, and with the constructor's number 2109 it was registered
Aircraft registration
An aircraft registration is a unique alphanumeric string that identifies a civil aircraft, in similar fashion to a licence plate on an automobile...
to the corporation as G-ARPI in 1961. By the time of the aircraft's first flight on the 14 April 1964 the company had become Hawker Siddeley Aviation, and Papa India was delivered to BEA on 2 May 1964.
While technically advanced, the Trident (and other aircraft with a T-tail
T-tail
thumb|right|Grob motor gliderA T-tail is an aircraft tail stabilizer configuration in which the horizontal surfaces are mounted to the top of the vertical stabilizer. Traditionally, the horizontal control surfaces are mounted to the fuselage at the base of the vertical stabilizer...
arrangement) had potentially dangerous stalling characteristics. If its airspeed
Airspeed
Airspeed is the speed of an aircraft relative to the air. Among the common conventions for qualifying airspeed are: indicated airspeed , calibrated airspeed , true airspeed , equivalent airspeed and density airspeed....
was insufficient, and particularly if its high-lift device
High-lift device
In aircraft design, high-lift devices are moving surfaces or stationary components intended to increase lift during certain flight conditions. They include common devices such as flaps and slats, as well as less common features such as leading edge extensions and blown flaps.-Purpose:Aircraft...
s were not extended at the low speeds typical of climbing away after take-off
Takeoff
Takeoff is the phase of flight in which an aerospace vehicle goes from the ground to flying in the air.For horizontal takeoff aircraft this usually involves starting with a transition from moving along the ground on a runway. For balloons, helicopters and some specialized fixed-wing aircraft , no...
or of approaching to land, it could enter a deep stall (or "superstall") condition from which recovery was practically impossible.
The danger first came to light in a near-crash during a 1962 test flight when de Havilland
De Havilland
The de Havilland Aircraft Company was a British aviation manufacturer founded in 1920 when Airco, of which Geoffrey de Havilland had been chief designer, was sold to BSA by the owner George Holt Thomas. De Havilland then set up a company under his name in September of that year at Stag Lane...
pilots Peter Bugge and Ron Clear were testing the Trident's stalling characteristics by pitching its nose progressively higher, thus reducing its airspeed: "After a critical angle of attack
Angle of attack
Angle of attack is a term used in fluid dynamics to describe the angle between a reference line on a lifting body and the vector representing the relative motion between the lifting body and the fluid through which it is moving...
was reached, the Trident began to sink tail-down in a deep stall." Eventually it entered a flat spin
Spin (flight)
In aviation, a spin is an aggravated stall resulting in autorotation about the spin axis wherein the aircraft follows a corkscrew downward path. Spins can be entered intentionally or unintentionally, from any flight attitude and from practically any airspeed—all that is required is sufficient yaw...
, and a crash "looked inevitable", but luck saved the test crew. The incident resulted in the Trident being fitted with an automatic stall warning system known as a "stick shaker
Stick shaker
A stick shaker is a mechanical device to rapidly and noisily vibrate the control yoke of an aircraft to warn the pilot of an imminent stall...
", and a stall recovery system known as a "stick pusher
Stick pusher
A stick pusher is a device installed in some fixed-wing aircraft to prevent the aircraft from entering an aerodynamic stall. Some large fixed-wing aircraft display poor post-stall handling characteristics or are vulnerable to deep stall...
" which automatically pitched the aircraft down in order to build up speed if the crew failed to respond to the warning.
These systems were the subject of "one of the most comprehensive stall programmes on record", involving some 3,500 stalls being performed by Hawker Siddeley before the matter "was squared off to the satisfaction of ... the ARB" (Air Registration Board). The stall warning and recovery systems tended to over-react: of ten activations between the Trident entering service and June 1972, only half were genuine, although there had been no false in-flight activations. BEA Trident pilots were questioned informally by one captain, over half of them said that they would disable the protection systems on activation, rather than let them recover the aircraft to a safe attitude. Random checks carried out by the airline after the accident showed that this was not the case; 21 captains stated that they had witnessed their co-pilots react correctly to any stall warnings.
Felthorpe accident
The aircraft type's potential to enter a deep stall was highlighted in the crash1966 Felthorpe Trident crash
The Felthorpe Trident crash occurred on 3 July 1966 when Hawker Siddeley Trident 1C G-ARPY entered a deep stall from which the crew were unable to recover. The aircraft crashed at Felthorpe, Norfolk killing all four crew. This was the first loss of a Trident aircraft.-Accident Flight:The flight was...
of Trident 1C, G-ARPY, on 3 June 1966 near Felthorpe
Felthorpe
Felthorpe is a civil parish in the English county of Norfolk.It covers an area of and had a population of 710 in 287 households as of the 2001 census.For the purposes of local government, it falls within the district of Broadland....
in Norfolk during a test flight, with the loss of all four pilots on board. In this accident the crew had deliberately switched off the stick shaker and stick pusher to perform their stall tests, and the probable cause was determined to be the crew's failure to take timely positive recovery action to counter an impending stall. The Confidential Human Factors Incident Reporting Programme (CHIRP), an experimental, voluntary, anonymous, and informal system of reporting hazardous air events introduced within BEA in the late 1960s, (later adopted by the Civil Aviation Authority and NASA
Aviation Safety Reporting System
The Aviation Safety Reporting System, or ASRS, is the US Federal Aviation Administration's voluntary system that allows pilots and other airplane crew members to confidentially report near misses and close calls in the interest of improving air safety...
), brought to light two earlier near-accidents, the "Orly" and "Naples" incidents, that involved flight crew error in the first case and suspicion of the Trident’s control layout in the second.
Orly incident
In December 1968 the captain of a Trident 1C departing Paris-Orly Airport for London attempted to improve climb performance by retracting the flapsFlap (aircraft)
Flaps are normally hinged surfaces mounted on the trailing edges of the wings of a fixed-wing aircraft to reduce the speed an aircraft can be safely flown at and to increase the angle of descent for landing without increasing air speed. They shorten takeoff and landing distances as well as...
shortly after take-off. This was a non-standard procedure, and shortly after he also retracted the leading edge droops
Leading edge slats
Slats are aerodynamic surfaces on the leading edge of the wings of fixed-wing aircraft which, when deployed, allow the wing to operate at a higher angle of attack. A higher coefficient of lift is produced as a result of angle of attack and speed, so by deploying slats an aircraft can fly at slower...
. This configuration of high-lift device
High-lift device
In aircraft design, high-lift devices are moving surfaces or stationary components intended to increase lift during certain flight conditions. They include common devices such as flaps and slats, as well as less common features such as leading edge extensions and blown flaps.-Purpose:Aircraft...
s at a low airspeed would have resulted in a deep stall, but fortunately the co-pilot noticed the error, increased airspeed and re-extended the droops, and the flight continued normally. The event became known as the "Paris Incident" or the "Orly Incident" among BEA staff.
Naples incident
In a further near-accident, a Trident 2E, G-AVFH, climbing away from London Heathrow for Naples in May 1970 experienced what was claimed by its flight crew to have been a spontaneous uncommanded retraction of the leading edge slats which was initially unnoticed by any of them. The aircraft’s automatic systems sensed the loss of airspeed and lift and issued two stall warnings. Since the crew did not initially detect anything amiss, they disabled the automatic system. While doing so, the first officer then noted and immediately remedied the problem by re-extending the retracted slats, and the flight continued normally.Investigations into the event found no mechanical malfunction that could have caused the premature leading edge device retraction, and stated that the aircraft had "just about managed to stay flying". A possible design fault in the high-lift control interlock
Interlock (engineering)
Interlocking is a method of preventing undesired states in a state machine, which in a general sense can include any electrical, electronic, or mechanical device or system....
s came under suspicion, although this was discounted during the investigation into the crash of Papa India. The event became known as the "Naples Incident" or the "Foxtrot Hotel Incident" (after the registration of the aircraft concerned) at BEA and was examined during the accident inquiry. The forward fuselage of this aircraft is preserved and on public display at the de Havilland Aircraft Heritage Centre
De Havilland Aircraft Heritage Centre
The de Havilland Aircraft Heritage Centre, formerly the Mosquito Aircraft Museum, is a volunteer-run aviation museum in London Colney, Hertfordshire, England...
, London Colney
London Colney
London Colney is a village and civil parish in Hertfordshire, England. It is located to the north of London, at Junction 22 of the M25 motorway....
.
Previous ground accident involving G-ARPI
An accident affecting the particular Trident operating as BE 548 had occurred on 3 July 1968. An Airspeed AmbassadorAirspeed Ambassador
The Airspeed AS.57 Ambassador was a British twin piston engined airliner that first flew on 10 July 1947 and served in small numbers through the 1950s and 1960s.-Design and development:...
freight aircraft, G-AMAD, deviated from the runway on landing at Heathrow due to a control failure and struck G-ARPI and its neighbouring sister aircraft, G-ARPT, while they were parked unoccupied near Terminal 1, resulting in six fatalities from the freighter's eight occupants. G-ARPT was damaged beyond economic repair, but G-ARPI was repaired at a cost of £750,000 and had performed satisfactorily thereafter.
Accident synopsis
Note: All timings in Greenwich Mean TimeGreenwich Mean Time
Greenwich Mean Time is a term originally referring to mean solar time at the Royal Observatory in Greenwich, London. It is arguably the same as Coordinated Universal Time and when this is viewed as a time zone the name Greenwich Mean Time is especially used by bodies connected with the United...
(GMT) from the official accident report.
Departure
The flight crew boarded BE 548 (call sign Bealine 548) at 15:20 to prepare for a 15:45 departure. The crew comprised CaptainPilot 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...
Stanley Key as P1, Second Officer
Second Officer (civil aviation)
A Second Officer usually refers to the third in the line of command for a flight crew on a commercial or non-military aircraft. Usually the Second Officer is a flight engineer who is also a licensed pilot. A Second Officer on some airlines is part of a relief crew. Rarely, such relief pilots are...
Jeremy Keighley as P2 and Second Officer Simon Ticehurst as P3. The captain was 51 and had accumulated 15,000 flying hours experience, of which 4,000 were on Tridents. Keighley was 22 and had joined line flying a month and a half earlier, with 29 hours as P2. Ticehurst was 24 and had over 1,400 hours, including 750 hours on Tridents.
Among the passengers were 29 Americans, 29 Belgians, 28 Britons, 12 Irish, four South Africans and three Canadians. There was also one passenger from each of French West Africa, India, Jamaica, Latin America, Nigeria and Thailand. There were between 25 and 30 women passengers and several children on board.
At 15:36 flight dispatcher J Coleman presented the load sheet to Key whose request for engine start clearance was granted three minutes later. As the doors were about to close, Coleman asked Key to accommodate a BEA flight crew which had to collect a Merchantman
Vickers Vanguard
The Vickers Type 950 Vanguard was a British short/medium-range turboprop airliner introduced in 1959 by Vickers-Armstrongs, a development of their successful Viscount design with considerably more internal room. The Vanguard was introduced just before the first of the large jet-powered airliners,...
aircraft from Brussels. The additional weight of the three crew members necessitated the removal of a quantity of mail and freight from the Trident to ensure its total weight (less fuel)
Maximum Zero-Fuel Weight
The Zero Fuel Weight of an airplane is the total weight of the airplane and all its contents, minus the total weight of the fuel on board....
did not exceed the permitted maximum of 41,730 kg. This was exceeded by 24 kg, but as there had been considerable fuel burnoff between startup and takeoff, the total aircraft weight (including fuel) was within the maximum permitted take-off weight.
The "dead-heading
Deadheading (aviation)
In aviation, deadheading is a term used when members of an airline's flight staff are carried free of charge but not working. This most often happens when airline crew are located in the wrong place and need to travel to take up their duties...
" crew was led by Captain John Collins, an experienced former Trident First Officer, who was allocated the observer's seat on the flight deck. One seat, occupied by a baby, was freed by the mother holding it in her arms.
The doors closed at 15:58 and at 16:00 Key requested pushback
Pushback
In aviation, pushback is an airport procedure during which an aircraft is pushed backwards away from an airport gate by external power. Pushbacks are carried out by special, low-profile vehicles called pushback tractors or tugs....
. At 16:03 BE 548 was cleared to taxi to the holding point adjacent to the start 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...
27 Right. During taxi, at 16:06 the flight received its departure route clearance: a routing known as the "Dover One Standard Instrument Departure". This Standard Instrument Departure
Standard Instrument Departure
Standard instrument departure routes, also known as departure procedures are published flight procedures followed by aircraft on an IFR flight plan immediately after take-off from an airport.- Introduction :...
involved taking-off to the west over 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...
localiser and middle marker beacon of the reciprocal Runway 09 Left, turning left to intercept the 145° bearing to the Epsom
Epsom
Epsom is a town in the borough of Epsom and Ewell in Surrey, England. Small parts of Epsom are in the Borough of Reigate and Banstead. The town is located south-south-west of Charing Cross, within the Greater London Urban Area. The town lies on the chalk downland of Epsom Downs.-History:Epsom lies...
Non-Directional Beacon
Non-directional beacon
A non-directional beacon is a radio transmitter at a known location, used as an aviation or marine navigational aid. As the name implies, the signal transmitted does not include inherent directional information, in contrast to other navigational aids such as low frequency radio range, VHF...
(NDB) (to be passed at 3000 feet (914.4 m) or more), and then proceeding to Dover
Dover
Dover is a town and major ferry port in the home county of Kent, in South East England. It faces France across the narrowest part of the English Channel, and lies south-east of Canterbury; east of Kent's administrative capital Maidstone; and north-east along the coastline from Dungeness and Hastings...
. Key advised the tower
Control tower
A control tower, or more specifically an Air Traffic Control Tower , is the name of the airport building from which the air traffic control unit controls the movement of aircraft on and around the airport. Control towers are also used to control the traffic for other forms of transportation such...
that he was ready for take-off and was cleared to do so. He subsequently reported an unspecified technical problem and remained at the holding point for two minutes to resolve it.
At 16:08 Key again requested and received take-off clearance. A cross wind was blowing from 210°
Boxing the compass
Boxing the compass is the action of naming all thirty-two points of the compass in clockwise order. Such names are formed by the initials of the cardinal directions and their intermediate ordinal directions, and are very handy to refer to a heading in a general or colloquial fashion, without...
at 17 knots (31 km/h). Conditions were turbulent, with driving rain and a low cloud base
Cloud base
This article refers to meteorology. For the airborne base of the TV series Captain Scarlet and the Mysterons, see Cloudbase.The cloud base is the lowest altitude of the visible portion of the cloud...
of 1000 feet (304.8 m); broken cloud was also reported at 600 feet (182.9 m). At 16:08:30, BE 548 began its take-off run which lasted 44 seconds, the aircraft leaving the ground at an indicated airspeed
Indicated airspeed
Indicated airspeed is the airspeed read directly from the airspeed indicator on an aircraft, driven by the pitot-static system. IAS is directly related to calibrated airspeed , which is the IAS corrected for instrument and installation errors....
(IAS) of 145 knots (284.2 km/h). The safe climb speed (V2)
V speeds
In aviation, V-speeds are standard terms used to define airspeeds important or useful to the operation of all aircraft including fixed-wing aircraft, gliders, autogiros, helicopters, and dirigibles...
of 152 knots (297.9 km/h) was reached quickly, and the undercarriage
Undercarriage
The undercarriage or landing gear in aviation, is the structure that supports an aircraft on the ground and allows it to taxi, takeoff and land...
was retracted. After 19 seconds in the air 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...
was engaged at 355 feet (108.2 m) and 170 knots (333.2 km/h); the autopilot’s airspeed lock was engaged even though the actual required initial climb speed was 177 knots (346.9 km/h).
At 16:09:44 (74 seconds after the start of the take-off run), passing 690 feet (210.3 m), Key commenced the turn towards the Epsom NDB and reported that he was climbing as cleared and the flight entered cloud. At 16:10 (90 seconds), Key commenced a standard noise abatement
Noise pollution
Noise pollution is excessive, displeasing human, animal or machine-created environmental noise that disrupts the activity or balance of human or animal life...
procedure which involved reducing engine power. As part of this, at 16:10:03 (93 seconds) he retracted the flaps from their take-off setting of 20°. Shortly afterwards, BE 548 reported passing 1500 feet (457.2 m) above ground level and was re-cleared to climb to 6000 feet (1,828.8 m) above sea level. During the turn, the airspeed decreased to 157 knots (307.7 km/h), 20 knots (39.2 km/h) below the target speed.
Stall warnings
At 16:10:24 (114 seconds), the leading edge devices were selected to be retracted at a height above the ground of 1770 feet (539.5 m) and a speed of 162 knots (317.5 km/h); 63 knots (123.5 km/h) below the safe droop-retraction speed of 225 knots (441 km/h). One second afterwards, visual and audible warnings of a stallStall (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...
activated on the flight deck, followed at 16:10:26 hrs (116 seconds) by a stick shake and at 16:10:27hrs (117 seconds) by a stick push which disconnected the autopilot, in turn activating a loud autopilot disconnect warning horn that continued to sound for the remainder of the flight. Key levelled the wings but held the aircraft's nose up, which kept the angle of attack
Angle of attack
Angle of attack is a term used in fluid dynamics to describe the angle between a reference line on a lifting body and the vector representing the relative motion between the lifting body and the fluid through which it is moving...
high, further approaching a stall.
By 16:10:32 (122 seconds), the leading edge devices had stowed fully into the wing. The speed was 177 knots (346.9 km/h), and height above the ground was 1560 feet (475.5 m), with the aircraft still held into its usual climb attitude. Key continued to hold the nose-up attitude when there was a second stick shake and stick push in the following two seconds. A third stick push followed 127 seconds into the flight but no recovery was attempted. One second later, the stall warning and recovery system was overridden by a flight crew member.
At 16:10:39 (129 seconds), the aircraft had descended to 1275 feet (388.6 m) and accelerated to 193 knots (378.2 km/h) as a result of the stall recovery system having pitched the aircraft's nose down to increase airspeed. G-ARPI was in a 16° banked turn to the right, still on course to intercept its assigned route. Key pulled the nose up once more to reduce airspeed slightly, to the normal 'droops extended' climb speed of 177 knots (346.9 km/h), but this further stalled the aircraft.
At 16:10:43 (133 seconds), the Trident entered a deep stall. It was descending through 1200 feet (365.8 m), its nose was pitched up by 31°, and its airspeed had fallen below the minimum indication of 54 knots (105.8 km/h). At 16:10:55 (145 seconds) and 1000 feet (304.8 m), the Trident was descending at 4500 ft/min. Impact with the ground came at 16:11 precisely, 150 seconds after brake release.
The aircraft just cleared high-tension
Electric power transmission
Electric-power transmission is the bulk transfer of electrical energy, from generating power plants to Electrical substations located near demand centers...
overhead power lines and came to rest on a narrow strip of land surrounded by tall trees immediately south of 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...
road, and a short distance south of the King George VI Reservoir
King George VI Reservoir
The King George VI Reservoir in England lies to the south of Stanwellmoor near Stanwell and Heathrow. The reservoir was opened in November 1947 and named after the then reigning monarch King George VI. It is owned by Thames Water....
near the town of Staines
Staines
Staines is a Thames-side town in the Spelthorne borough of Surrey and Greater London Urban Area, as well as the London Commuter Belt of South East England. It is a suburban development within the western bounds of the M25 motorway and located 17 miles west south-west of Charing Cross in...
.There was no fire on impact; however, one broke out during the rescue effort when cutting apparatus was used.
Eyewitnesses and rescue operations
There were three eyewitnesses to the impact; two brothers, Paul and Trevor Burke, aged 9 and 13, who were walking nearby, and a passing motorist who stopped and called at a house to telephone the airport authorities and advise them of the accident.Air traffic controllers had not noticed the disappearance from radar
Radar
Radar is an object-detection system which uses radio waves to determine the range, altitude, direction, or speed of objects. It can be used to detect aircraft, ships, spacecraft, guided missiles, motor vehicles, weather formations, and terrain. The radar dish or antenna transmits pulses of radio...
of BE 548, while the emergency services only became aware of the accident after 15 minutes had passed and did not know the precise circumstances of it for nearly an hour. First on the scene of the accident was a nurse who lived nearby, who had been alerted by the two boys, and an ambulance crew that happened to be driving past by chance. A male passenger who had survived the accident was discovered in the aircraft cabin, but died without recovering consciousness on arrival at Ashford
Ashford, Surrey
Ashford is a town almost entirely in the Surrey borough of Spelthorne in England, with a small part falling within Greater London. It is a suburban development situated 15 miles west south-west of Charing Cross in London and forms part of the London commuter belt...
Hospital. A young girl was also found alive but died at the scene; there were no other survivors. Altogether, 30 ambulances and 25 fire engines attended the accident.
Sensation-seeking occupants of cars formed heavy traffic jams soon after, and were described by Minister of Aerospace Michael Heseltine
Michael Heseltine
Michael Ray Dibdin Heseltine, Baron Heseltine, CH, PC is a British businessman, Conservative politician and patron of the Tory Reform Group. He was a Member of Parliament from 1966 to 2001 and was a prominent figure in the governments of Margaret Thatcher and John Major...
on BBC
BBC
The British Broadcasting Corporation is a British public service broadcaster. Its headquarters is at Broadcasting House in the City of Westminster, London. It is the largest broadcaster in the world, with about 23,000 staff...
Television that evening as "Ghouls, unfortunate ghouls". However the crash site was sufficiently inaccessible for the police to successfully control spectators, and contemporary reports that members of the public impeded rescue services by their presence near the site were dismissed during the subsequent inquiry.
A BEA Captain, Eric Pritchard, arrived at the accident scene shortly after the bodies had been removed, he noted the condition of the wreckage and drew his own early conclusions:
The accident became known as the Staines disaster, and was the worst air disaster in Britain prior to the Pan Am Flight 103
Pan Am Flight 103
Pan Am Flight 103 was Pan American World Airways' third daily scheduled transatlantic flight from London Heathrow Airport to New York's John F. Kennedy International Airport...
bombing over Lockerbie
Lockerbie
Lockerbie is a town in the Dumfries and Galloway region of south-western Scotland. It lies approximately from Glasgow, and from the English border. It had a population of 4,009 at the 2001 census...
, Scotland in 1988. The crash was also the first aviation disaster to occur in the United Kingdom involving the loss of more than 100 lives.
Investigation and public inquiry
On Monday 19 June 1972 Michael Heseltine announced to the British ParliamentParliament of the United Kingdom
The Parliament of the United Kingdom of Great Britain and Northern Ireland is the supreme legislative body in the United Kingdom, British Crown dependencies and British overseas territories, located in London...
that he had directed a Court of Inquiry, an ad hoc tribunal popularly called a "public inquiry
Public inquiry
A Tribunal of Inquiry is an official review of events or actions ordered by a government body in Common Law countries such as the United Kingdom, Ireland or Canada. Such a public inquiry differs from a Royal Commission in that a public inquiry accepts evidence and conducts its hearings in a more...
", to investigate and report on the accident. Public inquiries bypassed the usual British practice whereby the Accidents Investigation Branch (AIB) investigated and reported on air crashes, and were held only in cases of acute public interest. On 14 July, the High Court
High Court of Justice
The High Court of Justice is, together with the Court of Appeal and the Crown Court, one of the Senior Courts of England and Wales...
Judge Sir Geoffrey Lane
Geoffrey Lane, Baron Lane
Geoffrey Dawson Lane, Baron Lane AFC PC QC was a British Judge who served as Lord Chief Justice of England from 1980 to 1992. The later part of his term was marred by a succession of disputed convictions...
was appointed to preside over the inquiry as Commissioner.
The British aviation community was wary of public inquiries for several reasons. In such inquiries, AIB inspectors were on an equal footing with all other parties, and the ultimate reports were not drafted by them, but by the Commissioner and his or her Assessors. Proceedings were often adversarial, with counsel
Counsel
A counsel or a counselor gives advice, more particularly in legal matters.-U.K. and Ireland:The legal system in England uses the term counsel as an approximate synonym for a barrister-at-law, and may apply it to mean either a single person who pleads a cause, or collectively, the body of barristers...
for victims' families regularly attempting to secure positions for future litigation
Lawsuit
A lawsuit or "suit in law" is a civil action brought in a court of law in which a plaintiff, a party who claims to have incurred loss as a result of a defendant's actions, demands a legal or equitable remedy. The defendant is required to respond to the plaintiff's complaint...
, and deadlines were frequently imposed on investigators. Pressure of work caused by the Lane Inquiry was blamed for the death of a senior AIB inspector who committed suicide during the inquiry.
AIB investigation and coroner's inquest
The aircraft's two flight data recorderFlight data recorder
A flight data recorder is an electronic device employed to record any instructions sent to any electronic systems on an aircraft. It is a device used to record specific aircraft performance parameters...
s were removed for immediate examination, and investigations at the site of the accident were completed within a week. The wreckage of Papa India was then removed to a hangar
Hangar
A hangar is a closed structure to hold aircraft or spacecraft in protective storage. Most hangars are built of metal, but other materials such as wood and concrete are also sometimes used...
at the Royal Aircraft Establishment
Royal Aircraft Establishment
The Royal Aircraft Establishment , was a British research establishment, known by several different names during its history, that eventually came under the aegis of the UK Ministry of Defence , before finally losing its identity in mergers with other institutions.The first site was at Farnborough...
in Farnborough, Hampshire
Farnborough, Hampshire
-History:Name changes: Ferneberga ; Farnburghe, Farenberg ; Farnborowe, Fremborough, Fameborough .Tower Hill, Cove: There is substantial evidence...
, for partial re-assembly aimed at checking the integrity of its flight control systems. An inquest
Inquest
Inquests in England and Wales are held into sudden and unexplained deaths and also into the circumstances of discovery of a certain class of valuable artefacts known as "treasure trove"...
was held into the 118 deaths, opening on 27 June 1972.
The pathologist
Forensic pathology
Forensic pathology is a branch of pathology concerned with determining the cause of death by examination of a corpse. The autopsy is performed by the pathologist at the request of a coroner or medical examiner usually during the investigation of criminal law cases and civil law cases in some...
stated that Captain Key had a pre-existing heart condition, atherosclerosis
Atherosclerosis
Atherosclerosis is a condition in which an artery wall thickens as a result of the accumulation of fatty materials such as cholesterol...
, and had suffered a potentially distressing arterial event caused by raised blood pressure typical of stress. (This event was popularly interpreted by the public as a heart attack.)
It had taken place "not more than two hours before the death and not less than about a minute" according to the pathologist's opinion given as evidence during the public inquiry. In other words, Key could have suffered it at any time between the row in the crewroom and 90 seconds after the start of the take-off run or the instant of commencing noise abatement procedures. The pathologist could not specify the degree of discomfort or incapacitation which Key might have felt. The Captain's medical state continued to be the subject of "conflicting views of medical experts" throughout the inquiry and beyond.
Lane Inquiry
The public inquiry, known as the "Lane Inquiry", opened at the PiccadillyPiccadilly
Piccadilly is a major street in central London, running from Hyde Park Corner in the west to Piccadilly Circus in the east. It is completely within the city of Westminster. The street is part of the A4 road, London's second most important western artery. St...
Hotel in London on 20 November 1972, and continued for 37 business days until 25 January 1973 despite expectations that it would end sooner. It was opened by Geoffrey Wilkinson of the AIB with a description of the accident, and counsel for the relatives of the crew members and passengers then presented the results of their private investigations. In particular, Lee Kreindler of the New York City Bar
Association of the Bar of the City of New York
The New York City Bar Association , founded in 1870, is a voluntary association of lawyers and law students. Since 1896, the organization, formally known as the Association of the Bar of the City of New York, has been headquartered in a landmark building on 44th Street, between Fifth and Sixth...
presented claims and arguments which were considered tendentious and inadmissible by pilots and press reporters. They involved hypotheses
Hypothesis
A hypothesis is a proposed explanation for a phenomenon. The term derives from the Greek, ὑποτιθέναι – hypotithenai meaning "to put under" or "to suppose". For a hypothesis to be put forward as a scientific hypothesis, the scientific method requires that one can test it...
about the mental state of Captain Key, conjecture about his physical state (Kreindler highlighted disagreements between US and British cardiologists
Cardiology
Cardiology is a medical specialty dealing with disorders of the heart . The field includes diagnosis and treatment of congenital heart defects, coronary artery disease, heart failure, valvular heart disease and electrophysiology...
) and allegations about BEA management. The allegations were delivered using tactics considered as "bordering on the unethical". The inquiry also conducted field inspections, flew in real Tridents and "flew" the BEA Trident simulator
Flight simulator
A flight simulator is a device that artificially re-creates aircraft flight and various aspects of the flight environment. This includes the equations that govern how aircraft fly, how they react to applications of their controls and other aircraft systems, and how they react to the external...
as well as observing the Hawker Siddeley Trident control systems rig. Its members visited the reassembled wreckage of G-ARPI at Farnborough and were followed by the press throughout their movements. The bare facts being more-or-less uncovered soon after the event, the inquiry was frustrated by the absence on the accident aircraft of a cockpit voice recorder
Cockpit voice recorder
A cockpit voice recorder , often referred to as a "black box", is a flight recorder used to record the audio environment in the flight deck of an aircraft for the purpose of investigation of accidents and incidents...
.
The stall warning and stall recovery systems were at the centre of the inquiry, which examined in some detail their operation and why the flight crew might have overridden them. A three-way air pressure valve (part of the stall recovery system) was found to have been one-sixth of a turn out of position, and the locking wire
Safety wire
Safety wire or lockwire is common in the aircraft and racing industries as an extra precaution to keep vital fasteners from unintentionally loosening and parts from falling off due to vibration or other forces. The use of safety wire is a type of positive locking device. It also allows rapid and...
which secured it was missing. Calculations carried out by Hawker Siddeley determined that if the valve was in this position during the flight then the reduction in engine power for the noise abatement procedure may well have activated the warning light that indicated low air pressure in the system. The failure indications might have appeared just prior to take-off and could have accounted for the two-minute delay at the end of the runway.A captain who had flown Papa India on the morning of the accident flight noted no technical problems, and the public inquiry found that the position of the valve had no significant effect on the system.
Findings and recommendations
The Lane Report was published on 14 April 1973. Minister for Aerospace and Shipping Michael HeseltineMichael Heseltine
Michael Ray Dibdin Heseltine, Baron Heseltine, CH, PC is a British businessman, Conservative politician and patron of the Tory Reform Group. He was a Member of Parliament from 1966 to 2001 and was a prominent figure in the governments of Margaret Thatcher and John Major...
paid tribute to the work done by Mr Justice Lane
Geoffrey Lane, Baron Lane
Geoffrey Dawson Lane, Baron Lane AFC PC QC was a British Judge who served as Lord Chief Justice of England from 1980 to 1992. The later part of his term was marred by a succession of disputed convictions...
, Sir Morien Morgan
Morien Morgan
Sir Morien Bedford Morgan CB FRS, was a noted Welsh aeronautical engineer, sometimes known as "the Father Of Concorde"...
and Captain Jessop for the work they had carried out during the inquiry into the accident.
The inquiry's findings as to the main causes of the accident, were that:
- The captain failed to maintain the recommended airspeed.
- The leading edge devices were retracted prematurely.
- The crew failed to monitor airspeed and aircraft configuration.
- The crew failed to recognise the reasons for the stall warnings and stall recovery system operation.
- The crew wrongly disabled the stall recovery system.
Underlying causes of the accident were also identified:
- Captain Key was suffering from a heart condition.
- The presence of Captain Collins on the flight deck may have been a distraction.
- There was a lack of crew training on how to manage pilot incapacitation.
- The low flying experience level of Second Officer Keighley.
- Apparent crew unawareness on the effects of an aircraft configuration change.
- Unawareness of the crew regarding the stall protection systems and the cause of the event.
- The absence of a baulk mechanism to prevent droop retraction at too low an airspeed.
Recommendations included an urgent call for cockpit voice recorders and for closer cooperation between the Civil Aviation Authority and British airlines. Though the report covered the state of industrial relations at BEA, no mention was made of it in its conclusions, despite the feelings of observers that it intruded directly and comprehensively onto the flight deck of the stricken aircraft. BEA ceased to exist as a separate entity in 1974, when it and British Overseas Airways Corporation
British Overseas Airways Corporation
The British Overseas Airways Corporation was the British state airline from 1939 until 1946 and the long-haul British state airline from 1946 to 1974. The company started life with a merger between Imperial Airways Ltd. and British Airways Ltd...
merged to form British Airways
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...
. A recommendation of the report that all British-registered civil passenger-carrying aircraft of more than 27000 kg (59,524.8 lb) all-up weight should be equipped with cockpit voice recorders resulted in their fitting becoming mandatory on larger British-registered airliners from 1973.
One issue treated as secondary at the inquiry was the presence on the flight deck observer's seat of Captain Collins. The Lane report recommended greater caution in allowing off-duty flight crew members to occupy flight deck seats, and aired speculation that Collins might have been distracting his colleagues. Sources close to the events of the time suggest that Collins played an altogether more positive role by attempting to lower the leading edge devices in the final seconds of the flight.
There were protests at the conduct of the inquiry by BALPA (which likened it to "a lawyers' picnic"), and by the Guild of Air Pilots and Air Navigators
Guild of Air Pilots and Air Navigators
The Guild of Air Pilots and Air Navigators is one of the Livery Companies of the City of London. The Guild was established in 1929 and was granted the status of a Livery Company in 1956...
which condemned the rules of evidence adopted and the adversarial nature of the proceedings. Observers also pointed to an unduly favourable disposition by the inquiry to Hawker Siddeley, manufacturer of the Trident, and to the makers of the aircraft's systems. Debate about the inquiry continued throughout 1973 and beyond.
The accident led to a much greater emphasis on crew resource management
Crew Resource Management
Crew resource management or Cockpit resource management is a procedure and training system in systems where human error can have devastating effects. Used primarily for improving air safety, CRM focuses on interpersonal communication, leadership, and decision making in the cockpit...
training, a system of flight deck safety awareness that remains in use today.
Victims
Among those killed were 12 senior businessmen from the Republic of Ireland, including the head of the Confederation of Irish Industry, en route to Brussels for meetings preparatory to Ireland's accession to the European Economic CommunityEuropean Economic Community
The European Economic Community The European Economic Community (EEC) The European Economic Community (EEC) (also known as the Common Market in the English-speaking world, renamed the European Community (EC) in 1993The information in this article primarily covers the EEC's time as an independent...
. A referendum approving Ireland's entry
Third Amendment of the Constitution of Ireland
The Third Amendment of the Constitution of Ireland permitted the state to join the European Communities and provided that European law would take precedence over the constitution...
had been passed in May.
A group of 16 doctors and senior staff from the Royal London Homeopathic Hospital
Royal London Hospital for Integrated Medicine
The Royal London Hospital for Integrated Medicine is a specialist complementary medicine hospital located in London, United Kingdom...
were also on board the flight, and a memorial bench to them can be found close to Great Ormond Street Hospital in Queen Square.
Memorials
Two memorials to the crew and passengers were dedicated on 18 June 2004 in StainesStaines
Staines is a Thames-side town in the Spelthorne borough of Surrey and Greater London Urban Area, as well as the London Commuter Belt of South East England. It is a suburban development within the western bounds of the M25 motorway and located 17 miles west south-west of Charing Cross in...
.
The first is a stained glass window in St Mary's
St Mary's, Staines
St Mary's, Staines, is a church in the town and parish of Staines, in the Spelthorne borough of Surrey and the Greater London Urban Area. Located on a rise not far from the Thames at the west end of the town, the church is part of the Diocese of London within the Church of England...
church, Church Street. The second is a slightly more accessible area of reflection with seating on the Moormede estate, close to where the accident occurred. The memorial is in the park/play area near the end of Waters Drive in the Moormede Estate.
See also
- 1972 in aviation1972 in aviationThis is a list of aviation-related events from 1972:- Events :* Early in the year, the United States introduces the Walleye II optically guided glide bomb into service, employing it in the Vietnam War. It becomes known as the "Fat Albert."-January:...
- 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...
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Lists
- List of accidents and incidents involving commercial aircraft