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It
was June of 1972 and tensions were high
between employees of British European
Airways. Pilots were nearing a strike,
but not all of those employed by BEA
were in favour of the action.
Many of the older
pilots felt the action was
unprofessional. Particularly opposed to
the strike was Stanley Key, a highly
experienced captain. On the afternoon of
June 18, Key was in the crew room at
London Heathrow preparing for a flight
to Brussels. Another pilot questioned
Key regarding his position on the strike
to which Key responded with a violent
outburst. One of the pilots who
witnessed Key's outburst was second
officer Jeremy Keighley, a new BEA pilot
who was scheduled to fly with Key to
Brussels that afternoon.
Also scheduled to fly
that day was second officer Simon
Tricehurst, a slightly more experienced
co-pilot. It was the company's position
to have three pilots aboard the
aircraft, one of them sitting in seat
similar to a flight engineer's seat as
the "monitoring" position. The
"monitoring" pilot's job was to observe
the actions of the captain and co-pilot
and assist as directed by the captain.
They were also responsible for alerting
the crew to any deviations from standard
procedure. Because Keighley had not yet
had the opportunity to become qualified
as a "monitoring" pilot, he would be
flying in the right seat while
Tricehurst flew in the third seat behind
the two pilots.
......It
was just after 4pm when the Trident
taxied to runway 27R with a full load of
112 passengers. In addition to the crew
and passengers, a BEA Vangaurd freighter
crew was travelling to Brussels to pick
up an aircraft. The captain, John
Collins, himself a qualified Trident
captain, chose to ride in the jumpseat
behind Key. The weather was mild, but
there was a slight rainfall from the
clouds at 1,000ft. The aircraft took off
normally and began a southerly turn just
before climbing into the overcast layer.
After contacting London Centre, 548 was
cleared to 6,000ft, which was tersely
acknowledged by Key. This was the final
transmission from 548. Less than a
minute later, the Trident emerged from
the clouds in a nose-high attitude and
fell into a field just south of the A30,
a major thoroughfare to London. Though
there was little post-crash fire, all
aboard were killed.
Wreckage of 548...
Although
the Trident was not equipped with a
cockpit voice recorder (CVR), it was
equipped with a flight data recorder
(FDR). It became clear during
examination of the wreckage that the
aircraft was fully functional up to the
time of impact and that the accident was
caused by lack of airspeed causing a
stall. This stall was caused by
premature retraction of the leading-edge
droops. The only question which remained
was why a fully functional aircraft with
four qualified pilots on the flightdeck
was allowed to get too slow in an
improper configuration and stall. The
Trident was equipped with a stick-shaker
and stick-pusher system. This system
physically caused the control yoke to
vibrate when a stall was imminent to
warn pilots.
If corrective action
was not taken, it would then push the
control yoke forward, breaking the
stall. This system can be overridden by
a switch on the control console. Readout
of the FDR showed that 6 seconds after
Key's acknowledgment of London Centre's
clearance to 6,000ft, the droops were
retracted. The aircraft was at an
airspeed of 162kts, some 63kts below the
minimum droop retraction speed of
225kts. This immediately placed the
aircraft into a stalled condition which
activated the stick-shaker/pusher
system.
Activation of the
system automatically disengages the
autopilot as well. The stick-pusher
lowered the nose and unstalled the
wings, but with the autopilot disengaged
and the elevator trim still set for a
climb, the aircraft immediately pitched
back up into a stall attitude. The
stick-shaker again activated, but before
the stick-pusher could lower the nose a
second time, one of the crew members
turned the system off. Without
stick-pusher or crew intervention, the
aircraft rapidly pitched up in excess of
30 degrees and entered a deep stall
unrecoverable in T-tailed aircraft. It
was in this attitude that the aircraft
struck the ground, causing total
separation of the tail.
Further analysis of the FDR showed that
even prior to the retraction of the
droops, the aircraft had been operated
outside of normal BEA procedures. At
London Heathrow, BEA had a noise
abatement procedure which involved
accelerating to 177kts, retracting the
flaps, and then, after passing through
3,000ft, increasing power for a cruise
climb and retracting the droops through
225kts. Instead, 548 only reached a
maximum of 170kts before reducing power
for noise abatement and retracting
flaps, at which time airspeed bled off
to 157kts.
The
aircraft had just entered a turn and
started to accelerate again when the
droops were retracted. The minimum droop
retraction speed is clearly placarded on
the control console and is an integral
part of all pilot's Trident training.
BEA also had a policy prohibiting
retraction during turns. Despite all
these things, the situation was still
recoverable if the crew had either
increased speed or immediately
re-extended the droops.
Autopsies preformed on the flight crew
uncovered some clues as to what may have
happened on the flightdeck of 548.
Tricehusrt, Keighley, and Collins all
appeared to be healthy and normal.
Captain Key's autopsy, however, revealed
a severe case of narrowing arteries. In
addition, there was a tear in the wall
of one of the arteries.
Doctors
concluded that this tear was a result of
a sharp rise in blood pressure not more
than two hours prior to the accident.
Symptoms were likely to be
unconsciousness, with chest pain and
disturbance of though processes at the
very least. There is little doubt that
tensions on the flightdeck would be high
with the recent strife between
flightcrews regarding the strike. Both
Tricehusrt and Keighley were young,
inexperienced pilots while Key and
Collins were some of the most senior men
at the company. In addition, Keighley
had witnessed Key's outburst earlier and
knew of his temper.
Wreckage of 548
Given this situation,
it is unlikely that either of the two
younger men would be willing to point
out any discrepancies to the captain,
especially in the presence of another
senior captain. Key was known as a
precise and competent pilot and the
deviations from procedure were believed
to be because of his increasing chest
pain and distraction. Investigators did
not believe that Keighley would have
been responsible for the premature droop
retraction. Although he was a new
Trident second officer, he was fully
trained and capable of flying the
aircraft and was fully knowledgeable of
the droop limitations. Instead, it was
believed that Key, in his pain and
distraction, inadvertently retracted
them while possibly trying to retract
the already retracted flaps. Still,
there were three other pilots capable of
recognizing and correcting this mistake.
It was believed that the crew was
becoming aware of Key's degrading
condition at this point and were
distracted in attending to him.
Tricehurst's notepad
was found in the wreckage with the
clearance to 6,000ft written down,
indicating that he was probably not
watching when the droops were retracted.
It was widely believed by BEA pilots
that the stick-shaker/pusher system was
unreliable and it is likely that the
crew, when encountering the system
activation twice within several seconds,
decided that it was acting erroneously
and deactivated it. Though the exact
chain events could not be definitively
concluded, it is clear that something
distracted the crew from flying the
aircraft and properly intervening when a
problem arose.
......After
this accident, several recommendations
were put into practice at BEA and the
rest of the airline industry. The first
of these was the addition of a speed
limiting device which prevented droop
retraction below minimum droop speed.
Crews were also trained in stalls which
resulted from changes in aircraft
configuration. Cockpit voice recorders (CVR)
were also installed on all large
passenger aircraft in Britain. Finally,
BEA changed their medical examination
procedure, requiring stress EKGs rather
than resting EKGs.
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