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Evidence from Resource 3 pieces of evidence from this resource.

Air Accident Investigation Branch, Department of Transport - England (1990). Report on the accident to Boeing 737-400 G-OBME near Kegworth, Leicestershire on 8 January 1989; British Midlands Ltd; AAIB Report 4/90. AAIB Report 4/90. London: Department of Transport.

  2. Evidence Type: Excerpt from Accident Report
    Evidence: "Flight deck workload remained high as the first officer obtained details of the actual weather at East Midlands and attempted without success to programme the flight management system to display the landing pattern at East Midlands. This last activity engaged the first officer's attention for 2 minutes." (page 5)
    Issue: automation may demand attention (Issue #102) See Issue details
    Strength: +5
    Aircraft: B737-400
    Equipment: FMS

  4. Evidence Type: Excerpt from Accident Report
    Evidence: "A last factor which may have influenced this crew's behavior, given the stressful nature of the events, is the flight simulator training which they would have experienced. In the simulator virtually all engine problems result in an engine shutdown. Since this crew would have been under both practical and psychological pressure to come up with a programme of action, it cannot be regarded as surprising that the actions they embarked upon were those they had practised in the flight simulator. 2.1.4 Flight crew training The performance of flight crews in emergency situations may be regarded as a product of their natural ability and their training. It is possible to identify three aspects of the circumstances of this accident where a different pattern of training could have favourably influenced to outcome. The ability of the pilots to extract information from the EIS must be questioned, and so must the apparent lack of coordination between the flight deck and the cabin crew. The most important issue, however, concerns the preparation of pilots generally to cope with unforeseen situations which are not covered in their emergency checklists. ... No EIS equipped flight simulator was available at that stage and so the first few flights of pilots who were new to the EIS system were supervised under normal line checking procedures. The result of this pattern of training was that the first time that a pilot was likely to see abnormal indications on the EIS was in-flight in an aircraft with a failing engine." (page 108)
    Issue: training may be inadequate (Issue #133) See Issue details
    Strength: +4
    Aircraft: B737-400
    Equipment: automation

  6. Evidence Type: Excerpt from Accident Report
    Evidence: "3. Conclusions (a) Findings ... 15. The change from hybrid electro-mechanical instruments to LED displays for engine indications has reduced conspicuity, particularly in respect of the engine vibration indicators. No additional vibration alerting system was fitted that could have highlighted to the pilots which of the two engines was vibrating excessively." (page 143)
    Issue: displays (visual and aural) may be poorly designed (Issue #92) See Issue details
    Strength: +4
    Aircraft: B737-400
    Equipment: displays
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