Incident Overview

Date: Sunday 18 June 1972
Aircraft Type: Hawker Siddeley HS-121 Trident 1C
Owner/operator: British European Airways – BEA
Registration Number: G-ARPI
Location: near Staines – ÿ United Kingdom
Phase of Flight: Initial climb
Status: Destroyed, written off
Casualties: Fatalities: 118 / Occupants: 118
Component Affected: Aircraft Control Systems (specifically, droop and speed control) and Pilot’s Monitoring.Aircraft Control Systems (specifically, droop and speed control) and Pilot’s Monitoring.
Investigating Agency: AIBAIB
Category: Accident
Flight BE548 experienced a significant incident during its scheduled flight from London to Brussels. The flight commenced with clearance at 15:39, followed by a push-back at 16:00, and then taxi to runway 28R at 16:03. The crew initiated takeoff at 16:06:53, utilizing a takeoff safety speed of 177 knots, with flap and leading edge droop extended. The takeoff was normal, with a 20ø flap, leading edge droop, and engine thrust set below full power. The aircraft rotated at 42 seconds, departing the runway at 145 knots IAS, and then proceeded to a 20ø banked turn to port, establishing the initial climb. The autopilot was engaged for 355 feet, then transitioned to a 20ø turn, and the aircraft accelerated to 225 knots, retracting the leading edge and establishing the en route climb. At 90 seconds, the crew reported ‘Climbing as cleared’, and the captain initiated the ‘Passing 1500’ message. The aircraft then cleared to climb to Flight Level 60, with the initial airspeed at 162 knots and altitude at 1772 feet. The stall recovery system was activated, resulting in a rapid pitch down and stick-pusher movement. The pilot’s heart condition was identified as abnormal, contributing to the incident. The incident was triggered by a combination of factors including insufficient speed after noise abatement procedures, droop-retraction, monitoring speed error, and failure to diagnose the cause of the stick-pusher operation.Flight BE548 experienced a significant incident during its scheduled flight from London to Brussels. The flight commenced with clearance at 15:39, followed by a push-back at 16:00, and then taxi to runway 28R at 16:03. The crew initiated takeoff at 16:06:53, utilizing a takeoff safety speed of 177 knots, with flap and leading edge droop extended. The takeoff was normal, with a 20ø flap, leading edge droop, and engine thrust set below full power. The aircraft rotated at 42 seconds, departing the runway at 145 knots IAS, and then proceeded to a 20ø banked turn to port, establishing the initial climb. The autopilot was engaged for 355 feet, then transitioned to a 20ø turn, and the aircraft accelerated to 225 knots, retracting the leading edge and establishing the en route climb. At 90 seconds, the crew reported ‘Climbing as cleared’, and the captain initiated the ‘Passing 1500’ message. The aircraft then cleared to climb to Flight Level 60, with the initial airspeed at 162 knots and altitude at 1772 feet. The stall recovery system was activated, resulting in a rapid pitch down and stick-pusher movement. The pilot’s heart condition was identified as abnormal, contributing to the incident. The incident was triggered by a combination of factors including insufficient speed after noise abatement procedures, droop-retraction, monitoring speed error, and failure to diagnose the cause of the stick-pusher operation.

Description

Flight BE548 was a scheduled passenger service from London to Brussels. Start-up clearance was given at 15:39 for a scheduled departure time of 15:45. Push-back was not requested until 16:00 due to load re-adjustment. Clearance to taxi was given at 16:03. The HS-121 Trident taxied to runway 28R for takeoff. At 16:06:53 the crew reported ready for takeoff. Takeoff clearance was given and at 16:08:30 the brakes were released. The standard BEA practice for this particular flight involved a takeoff with 20ø flap, leading edge droop (wing leading edge slats) extended and the engine thrust at settings below full power. After takeoff speed should be increased to the initial climb speed VNA (ie, takeoff safety speed, V2 plus 25 knots). The scheduled value of VNA for this flight was 177 knots Indicated Air Speed (IAS). At 90 seconds from brakes-off flaps are to be selected fully up and the engine thrust reduced to the noise abatement settings. At 3,000 feet climb power is to be set and then as the aircraft accelerates and reaches 225 knots the leading edge is retracted and the en route climb established. The minimum droop retraction speed is placarded by the lever and is well-known to all pilots. The takeoff was normal and at 42 seconds the aircraft rotated, leaving the runway 2 seconds later at 145 knots IAS. At 63 seconds the autopilot was engaged 355 feet above the runway at 170 knots IAS; the IAS speed lock was selected shortly thereafter. At 74 seconds the aircraft started a 20ø banked turn to port towards the Epsom Non-Directional Beacon (NDB). At 83 seconds the captain reported ‘Climbing as cleared’. He was then instructed to change frequency and contact London Air Traffic Control Centre. At 93 seconds the noise-abatement procedure was initiated. On the assumption that the captain was the handling pilot, this would involve the second officer selecting the flaps fully up and operating the thrust levers to reduce power to the pre-calculated figure. At 100 seconds the captain called ‘Passing 1500’ and at 103 seconds the aircraft was cleared to climb to Flight Level 60. This message was acknowledged by the captain at 108 seconds with the terse call ‘up to 60’. This was the last message received from the flight. At second 114 when the airspeed was 162 knots and the altitude 1,772 feet, the droop lever was selected up putting the aircraft into the area of the stall as the droop started to move. At second 116 the stick-pusher stall recovery device operated, causing the autopilot automatically to disengage and the nose of the aircraft to pitch down and the stick-push to cease as the incidence decreased. Since the elevator trim would stay at its position on autopilot disengagement which at that speed with the droop up would be – the incidence then increased causing a second stick-push at second 124 and a third at second 127. At second 128 the stall recovery system was manually inhibited by pulling the lever. The aircraft then pitched up rapidly, losing speed and height, entering very soon afterwards the true aerodynamic stall and then a deep stall from which at that height no recovery was possible. Impact was at second 150 in a field next to the A30 motorway . PROBABLE CAUSE: Immediate causes were: 1) Failure by PIC to achieve and maintain adequate speed after noise-abatement procedures; 2) Droop-retraction 60kts below minimum speed.; 3) Failure to monitor speed error and to observe droop lever movement.; 3) Failure to diagnose reason for stick-pusher operation and warnings; 4) Operation of stall recovery override lever. A factors was a.o. the abnormal heart condition of the captain.

Primary Cause

Failure to achieve and maintain adequate speed after noise-abatement procedures, combined with insufficient droop-retraction and monitoring of speed error.Failure to achieve and maintain adequate speed after noise-abatement procedures, combined with insufficient droop-retraction and monitoring of speed error.

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