An easyJet plane flying over a British city was within seconds of crashing after plummeting at a rate of 21,000ft-per-minute in a near-nosedive, it has been revealed.
The Air Accidents Investigation Branch (AAIB) said the plane – a widely-used Boeing 737 – lost height at 350 feet a second before the two pilots managed to recover control.
The AAIB blamed the January 12 incident on ‘confusion between the two pilots’ and described the event as ‘serious’.
The plane was on a test flight over Norfolk at the time of the incident.
At 15,000ft above the Norwich area, the hydraulic systems that help move the plane’s rudder, ailerons and elevators were switched off as part of a routine test.But unknown to the 43-year-old captain, a misunderstanding following a previous test flight had led to the elevator balance tabs being adjusted in the opposite direction to that intended. When the power was cut to the hydraulics, the plane therefore entered a violent dive.
Though he used ‘considerable force’ on his controlsthe captain was unable to prevent the plane plummeting towards the ground at a rate of 350 feet per second. He rolled the aircraft left at more than 90 degrees to try to stabilise it and made an emergency call to air traffic controllers.
After the incident, the flight was abandoned and the pilots took the plane safely back to Southend. The plane had come to the end of its lease and had just undergone maintenance before being handed on to another operator.
Back in December, the same test flight captain had flown the plane and noted that the “amount of manual stabiliser trim wheel adjustment” required to balance the aircraft in level flight was only just within the approved maintenance manual limits.
After that flight, the captain had also verbally requested that the matter be looked at – but did not to enter it in the tech log. The report said: “The absence of a formal post-flight debrief and formal written record resulted in the balance tabs, attached to the elevators of the aircraft, being adjusted in the opposite sense to that identified as necessary by the [December] flight test.
“The aircraft was therefore significantly out of trim during the post-maintenance test flight and it was that which initiated the pitch-down incident.”
The AAIB said easyJet suspended further check flights until it had carried out a review of maintenance procedures, check-pilot procedures and flight-check procedures.
Source: http://news.aol.co.uk/airliner-in-nosedive-above-british-city/article/20090304051809990002
By: Cking - 5th March 2009 at 23:17
This is a classic human factors issue.
Amen to that, just look
I see it one way, you guys see it another, and this is just the internet!!
Thank god this incident ended happily
Rgds Cking
By: HP81 - 5th March 2009 at 21:49
The work carried out was recorded. However the request to carry out that work did not come directly from the pilot who felt that the adjustment was necessary. Accurate information is essential for this type of work & second hand reports are not the best way to proceed.
By: bloodnok - 5th March 2009 at 18:14
The report said: “The absence of a formal post-flight debrief and formal written record resulted in the balance tabs, attached to the elevators of the aircraft, being adjusted”
That sounds like un recorded work to me.
Rgds Cking
That to me says the pilot asked the groundcrew to adjust the trim tabs, but didn’t write up a snag.
The groundcrew adjusted the tabs, but because the snag wasn’t written down anywhere, they adjusted it the wrong way.
I’d have said the ground crew would have written up the work correctly, otherwise there’d be no record of them of the moving the tabs the wrong way.
This is a classic human factors issue.
By: cal900 - 5th March 2009 at 18:08
Quite worrying really as someone who lives just west of Norwich where this is meant to have happend.
By: Cking - 5th March 2009 at 13:35
I do not think the engineering work was unrecorded, as it was noted that the balance tabs had been adjust since it’s last flight. What was unrecorded was the pilots desire for the balance tabs to be adjusted, only communicated verbally.
The report said: “The absence of a formal post-flight debrief and formal written record resulted in the balance tabs, attached to the elevators of the aircraft, being adjusted”
That sounds like un recorded work to me.
Rgds Cking
By: Cking - 5th March 2009 at 13:19
I am amazed!!!!!
Un recorded work carried out on flying controls. That is bad in so many ways.
When a pilot doesn’t put something in the book, it can’t be that bad. If he thought it needed adjusting he SHOULD have put it in the book.
If he asks you to have a look at something, have a look and if you find anything, RECORD what you find and then fix it.
Also when you are adjusting flying controls, you HAVE to have your work checked by somebody else. (A duplicate inspection)
All three of those basic mistakes, you are warned about from day one of your training.
Rgds Cking
By: Bograt - 5th March 2009 at 12:35
The incident is the subject of an AIRCOM released yesterday…
http://www.caa.co.uk/application.aspx?catid=33&pagetype=65&appid=11&mode=detail&id=3452
AAIB report here
http://www.aaib.gov.uk/publications/special_bulletins/s2_2009___boeing_737_73v__g_ezjk.cfm
A bit of a complex issue with the interface between operator, CAMO and maintenance provider.
By: Bmused55 - 5th March 2009 at 12:20
Would be interesting to see if the quotes descent rates are true or just typical media hyperbole?
By: steve rowell - 5th March 2009 at 00:57
Thank goodness it wasn’t a revenue flight…it would have been quite hair raising!!!
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March 5, 2009 at 12:00 am