LAX772LR wrote:

PPVLC wrote:

Yes, Concorde was getting too old and costly, and reached retirement age that's the plain fact.

Actually, it isn't. Costly, yes.

"Old"... no. Not in the sense that would apply to aircraft. Several of the aircraft, (G-BOAF, G-BOAE, F-BVFF if it had been retrofitted, etc) had were relatively light on design hours and cycles, and could've easily operated another decade or more, were they tasked to.

Please don't tell me that, it just breaks my heart, let me carry on believing it was age...

British Midland 737 crash at Kegworth. Changes in seat structures and brace positions to enhance survivability.

But I agree the industry learns from each and every crash.

Delta flight 191, a L1011 from FLL-DFW on Aug 2, 1985

The NTSB attributed the accident to lack of the ability to detect microbursts aboard aircraft – the radar equipment aboard aircraft at the time was unable to detect wind changes, only thunderstorms. After the investigation, NASA researchers at Langley Research Center modified a Boeing 737-200 as a testbed for an on-board Doppler weather radar. The resultant airborne wind shear detection and alert system was installed on many commercial airliners in the United States after the FAA mandated that all commercial aircraft must have on-board windshear detection systems.

US 427 anyone? How intense an investigation that was, and the discovery that the CPU could cease to function or even reverse after being at altitude

I believe that Southern Airways Flight 242, a DC-9 that crashed in a severe thunderstorm in the 1970's changed the way severe thunderstorms are reported in via air traffic control. The FAA adopted a standard (1-6 range) severity scale for thunderstorms reporting, improved AIRMET and SIGMET reporting and NWS (the U.S. Met Office) Severe Weather bulletins were to be transmitted to FAA facilities.

Weather radar wasn't what it is today

Lots of great posts on here.

Eastwind 517 was pretty important. It allowed investigators to interview pilots who experienced a 737 rudder hard-over/reversal which played in big role in solving a serious condition which had stumped many.

Stitch wrote:

ro1960 wrote:

What about the crash of the AF A320 during a demo flight in 1988? First commercial fly-by-wire flight.

The FBW system worked correctly in that accident, as I recall. I believe the real cause was Pilot Error in picking the wrong runway (the one he thought he was on did not have a forest at the end) and flying too low and too slow.

I was not asking about the cause of the accident but the lessons learned from the mistake (as per the current topic).

How about Turkish Airlines flight 981, the DC10 crash near Paris. The crash was caused by an improperly secured cargo door in the rear of the plane that broke off. Explosive decompression, severed cables and all ... did this lead to any corrections in design or procedure? There was another crash (or incident) with American Airlines in 1972 called the Windsor incident? Any additional information or insight is welcome.

Great topic.

As recommended by a fellow AV, obtain a copy of Loud and Clear by Robert Serling. It was published in 1969 and offers an interesting look into aviation accidents during that time. You get an understanding of how aviation safety continues to evolve.

Behind the Iron Curtain, An-10 crash near Kharkov was a major deal in aircraft design, manufacturing, maintenance and operation.
https://en.wikipedia.org/wiki/Aeroflot_Flight_1491
AFAIR, a very new and light-weight alloy was used in center wing box of this airplane model. The alloy would degrade with time; vibration sped up this aging.
The situation was exacerbated by the fact that the plane was certified for operating from unpaved strips (grass, other rough fields).
Designers, Antonov Design Bureau (Kiev, Ukraine), did the necessary testing to prove this capability, but never realized that the operators (various operating companies of Ministry of Air Transport of USSR, a.k.a. "Aeroflot") would continuously abuse the frames in this way. When the degradation from increased stresses and vibration was initially observed, the designers issued a bulletin to fix the problem (basically manufacturing new center wing box and replacing on all airplanes). The manufacturer (Voronezh aviation plant, Russia), being part of Ministry of Aircraft Production of USSR, was too busy with urgent (apparently military) orders, and in general this order was not in their five-year plan; modification was postponed to some later date. So the fleet continued to fly to whatever available fields and accumulate fatigue until flight 1491 crashed. An-10 was immediately retired, despite being a money-maker for Aeroflot, and safety again returned as a priority for the participating parties.

CairnterriAIR wrote:

AA 191. A big lesson in performing scheduled maintenance by the book and not via shortcuts.

I understand this was more of a contributing factor, but did AA 191 have any impact on aviation design. As I remember, the DC-10 had it's primary and secondary hydraulic systems co-located so when the engine tore away from the wing, it took out both systems. This led to the loss of control that ultimately led to the crash as the plane could have continued to fly with only 2 engines otherwise. If I remember correctly, Boeing didn't co-locate the hydraulics like Douglas did. I would think separating these systems would apply to FBW also. Please don't flame me for my oversimplification and non-technical description/question.

ro1960 wrote:

Stitch wrote:

ro1960 wrote:

What about the crash of the AF A320 during a demo flight in 1988? First commercial fly-by-wire flight.

The FBW system worked correctly in that accident, as I recall. I believe the real cause was Pilot Error in picking the wrong runway (the one he thought he was on did not have a forest at the end) and flying too low and too slow.

I was not asking about the cause of the accident but the lessons learned from the mistake (as per the current topic).

I'm not sure there were any lessons to be learned. If the plane had been a 737 (so no FBW), it still would have gone into the woods because the engines would not have spooled up any faster and therefore not provided enough thrust to recover and yanking back on the yoke would have stalled the frame and it would have crashed, as well.

It tends to be overshadowed by the Grand Canyon midair in 1956, but UAL 736 on April 21, 1958 - in which a U.S. Air Force F-100F collided with a United DC-7 south of Las Vegas, NV - was another accident that drove the creation of the Federal Aviation Agency (later Administration) as a single governing entity over all U.S. airspace. It also led to the requirement that military aircraft communicate with civilian controllers when operating in civil airspace.

My maternal grandfather was one of the 47 fatalities onboard the DC-7. Both airmen in the F-100F also lost their lives.

pdx wrote:

ImperialEagle wrote:

The UA DC-8 crash in Denver taught valueable lessons about lack of CRM. The NW 720B crash into the Everglades in the early sixties certainly effected how jets were operated and brought about a lot of research into " jet-upset". The BA 707 crash near Mt. Fuji in the mid-sixties taught valuable lessons about clear air turbulence. The DL DC-8 training accident at MSY put the focus on questionable FAA training procedures. I can think of many other examples. The important thing is that the industry has learned from every single accident. Sadly, sometimes needless lives were lost going down the learning curves. Air travel today is way safer then it was when I was young!

There was a UA DC-8 crash in Portland, OR on 12/28/78. Is that the one you're talking about?

UA859 July 11, 1961. Hydraulic issues created ejector ring/reverser issues. As with most accidents a series of events played out. At that time UA had some bizarre cockpit procedures. It was like trying to drive a car with two steering wheels. Also training issues as the crew seemed unaware of a reverse thrust back up system they could have used to blast the ejector rings into place. As I recall, there were also issues evacuating the cabin and I think the use of JP4 complicated things as well. Lots of lessons from this one, however, it took years and other deaths before changes were made.

Stitch wrote:

I'm not sure there were any lessons to be learned. If the plane had been a 737 (so no FBW), it still would have gone into the woods because the engines would not have spooled up any faster and therefore not provided enough thrust to recover and yanking back on the yoke would have stalled the frame and it would have crashed, as well.

Actually after I little internet research, some recommendations about came out of the investigation. The BEA recommended that:

Passengers should be banned from all demonstration flights
Flight crews should be provided with – and ensure proper reconnaissance – of airfields
Airline company procedures should be reviewed to ensure they comply with official regulations concerning altitude

To stay on topic, I'm curious if any have of them have been implemented for demo flights at air shows.

Simple way to improve air safety. Ban the use of flight no 191. DL 191 went down short of DFW in a microburst. AA 191 crashed off of ORD after losing an engine (litterally) and Comair 191 took off on the wrong runway and crashed. Spooky. None of these carriers uses 191 in their systems today.

I concur with the other posters that have mentioned what a great topic this is. One of the best this site has had in a while.

Other posters have mentioned the American Eagle crash at Roselawn, IN, as well as CO Express at BUF. Though I can't recall a specific incident (I know someone will chime in), there were a series of crashes in the 90s on the commuter/regional side that forever changed the....trajectory....of that portion of the industry.

The most notable aspect of the changes that occurred resulted in the FAA reclassifying the scheduled commuter carriers from Part 135 to Part 121. That administrative change resulted in revised (upgraded) pilot training requirements, maintenance practices, dispatch procedures, emergency training....just a litany of changes, invisible to the public, that ultimately curtailed the use of turboprops because of the financial implications of the increased oversight.

While the advent of the regional jets surely played a hand in the demise of turboprops, that contributing factor was more a result of the major carriers dictating the operations/services provided to them by regional carriers.

The one notable commuter/regional incident that comes immediately to mind was the Air Midwest/US Airways Express crash at CLT in (IIRC) 2003. The end result was a change in weight & balance calcs for, essentially, any commuter-type airframe that in scheduled operations exceeded certain aircraft seating capacity & weight standards as set by the FAA.

bohica wrote:

TheFlyingDisk wrote:

trnswrld wrote:

[snip]

Back in the 70's there were a couple crashes, TWA near IAD and Eastern near CLT. In both accidents, there was unnecessary conversation in the cockpit. These accidents resulted in the sterile cockpit rule.


[snip]

Yes, Eastern Airlines 212 in 1974 is considered the genesis of the "Sterile Cockpit" rule (no extraneous conversation/activity under 10,000 feet)

A little-remembered accident which is a charter-operator corollary to advocate CRM sterile-cockpit procedures was the Aspen, Colorado Gulfstream III crash in 2001 as pilots searched for the runway in snow as darkness fell, in which one of the key links in the accident chain was the presence of the charter customer sitting in the cockpit during the final minutes of flight, putting pressure on the pilots not to divert to the alternate airport of Rifle, Colorado and spoil an expensive dinner the customer was throwing in Aspen for the rest of the passengers. I lost a young friend in this one and the NTSB transcript is haunting because it's one of those classic swiss-cheese ones where you can see the accident coming before the flight even took off from LAX.

What was that crash that changed standard weights for passengers from 170/175lbs to 190/195lbs?

One of the first big airplane accidents that changed aviation was the March 31, 1931 crash of TWA Flight 599 in Kansas in a Fokker F-10 Trimotor. It was best known for the death of Knute Rockne, the star football coach at University of Notre Dame. That there was the death of a well known national celebrity brought attention to it crash and people wanting to know why it happened. This crash is an important 'game changer' in several ways as to aviation we still benefit from today.
It led to developing comprehensive investigations of all airline crashes in the USA and later around the world by a specialized government agency. As a result of the investigation, it found serious flaws in the design, due to de-lamination of certain composite wood structures. This led to basically ending the use of wood in aircraft structures and moving to aluminum. The Ford Trimotor was already in use and had an all metal framework. It also encouraged the next generation of larger passenger aircraft including the Boeing 247 and DC-1/DC-2/DC-3 series.

United787 wrote:

CairnterriAIR wrote:

AA 191. A big lesson in performing scheduled maintenance by the book and not via shortcuts.

I understand this was more of a contributing factor, but did AA 191 have any impact on aviation design. As I remember, the DC-10 had it's primary and secondary hydraulic systems co-located so when the engine tore away from the wing, it took out both systems. This led to the loss of control that ultimately led to the crash as the plane could have continued to fly with only 2 engines otherwise. If I remember correctly, Boeing didn't co-locate the hydraulics like Douglas did. I would think separating these systems would apply to FBW also. Please don't flame me for my oversimplification and non-technical description/question.

Not so much AA 191 but UAL 232 in SUX which # 2 engine uncontained failure took out all 3 hydraulic systems. After that accident they installed what was affectionately known as the Sioux City mod which was the installation of hydraulic fuses to contain hydraulic fluid loss in the event of a damaged hyd system. Another accident that induced change was the ValuJet DC-9 crash which mandated cargo compartments on older aircraft be changed from a class D to a class C requiring smoke detection and suppression.

stratosphere wrote:

United787 wrote:

CairnterriAIR wrote:

AA 191. A big lesson in performing scheduled maintenance by the book and not via shortcuts.

I understand this was more of a contributing factor, but did AA 191 have any impact on aviation design. As I remember, the DC-10 had it's primary and secondary hydraulic systems co-located so when the engine tore away from the wing, it took out both systems. This led to the loss of control that ultimately led to the crash as the plane could have continued to fly with only 2 engines otherwise. If I remember correctly, Boeing didn't co-locate the hydraulics like Douglas did. I would think separating these systems would apply to FBW also. Please don't flame me for my oversimplification and non-technical description/question.

Not so much AA 191 but UAL 232 in SUX which # 2 engine uncontained failure took out all 3 hydraulic systems. After that accident they installed what was affectionately known as the Sioux City mod which was the installation of hydraulic fuses to contain hydraulic fluid loss in the event of a damaged hyd system. Another accident that induced change was the ValuJet DC-9 crash which mandated cargo compartments on older aircraft be changed from a class D to a class C requiring smoke detection and suppression.

And what's confounding about UA 232 is that one would have thought that AA 191 would have laid bare the fundamental issue of back-up hydraulics, some 10 years before SUX became the ultimate failure scenario .... but - nope. I can't help but regard UA 232 as as much a failure of the aviation oversight agencies, as of McDonnell-Douglas.

How is it that the American auto industry went to the dual-chamber master brake cylinder system in 1966, so as to avoid total brake failure and allow one half of the system to work if one wheel cylinder or hose leaked (as opposed to the old single-chamber design in which one leak doomed the whole system), and yet the 1979 grounding of an entire mainline aircraft type, a drastic and crippling step not repeated until Concorde, didn't result in the bullet-proofing of the DC-10 hydraulic system then and there?

I hope that things have tightened up in the intervening years. The 787 lithium battery saga may be evidence that it has!

And yes, we need to include the 787 battery fires as (near)-accidents that did ground a type and put the screws to Boeing (hopefully) to fix it.

All great examples. With fatal accidents being so rare now, I am surprised few have discussed the most recent accidents at more length.

Egypt Air in the Mediterranean.
FlyDubai in Rostov on Don
Air France 447
Air Asia Express
Continental Express in BUF.
I forgot.... The accident where the Brazilian airliner ran off the runway in Sao Paolo and killed everyone.
Afriqueyah in Tripoli.

We can talk the rest of our lives about old accidents and what has changed.

Accidents are so, so, so rare. Why not focus on the most recent?

I also think accidents resulting from shocking pilot error are the most tragic and really worth discussion. Like Eastern Airlines, crashing over a lightbulb malfunction, where no one was actually flying the plane. I just watched Mayday on the NW Airline crash in Hibbing MN. Another pilot error incident. I know, those are old ones.

airmagnac wrote:

SomebodyInTLS wrote:

Well, I was just a little surprised that in a thread such as this the top contenders (from an engineer's point of view) were missing!

Well at least for a structures engineer !

Touché!

airmagnac wrote:

- from : a colleague in the systems department

Go back to your pipes...

skymiler wrote:

Air Canada 797 at CVG.

I lost a friend in that tragedy, but every time I hear the announcement for the emergency lights (which is up to 150+ times a year) I am grateful that the loss of his life was not in vain.

Air Canada 797???????

akelley728 wrote:

Delta flight 191, a L1011 from FLL-DFW on Aug 2, 1985

The NTSB attributed the accident to lack of the ability to detect microbursts aboard aircraft – the radar equipment aboard aircraft at the time was unable to detect wind changes, only thunderstorms. After the investigation, NASA researchers at Langley Research Center modified a Boeing 737-200 as a testbed for an on-board Doppler weather radar. The resultant airborne wind shear detection and alert system was installed on many commercial airliners in the United States after the FAA mandated that all commercial aircraft must have on-board windshear detection systems.

Agreed - this one really jumps out at me. Not only was it my favorite aircraft, but also in the "golden days" of air travel. Also, the crew was incredibly skilled, professional, and experienced - not only with the aircraft, but in microburst detection.

In a tough-to-recognize situation, they not only noticed it, but executed near textbook commands to counter the threat. Yet sadly, it was just too severe for a large and slow aircraft on approach at low altitude.

I think the most fundamentally important events are the ones where people did their jobs and the system failed them. Something clearly needed to be changed and/or upgraded in the wake of this event. It was - and *knock on wood* similar events of this type are now a thing of the past, at least on this scale.

BravoOne wrote:

skymiler wrote:

Air Canada 797 at CVG.

I lost a friend in that tragedy, but every time I hear the announcement for the emergency lights (which is up to 150+ times a year) I am grateful that the loss of his life was not in vain.

Air Canada 797???????

That was the flight number.

AA 191 - Dont take shortcuts in maintenance of a plane/Dont repair planes with a fork lift
JL 123 - Dont take shortcuts on repairs/Use two rows of rivets instead of one when asked
VJ 592 - Dont put flammables in the cargo hold unchecked/Dont let people who have no clue what theyre doing set up cargo manifest
AF 447 - Dont have the most experienced pilot leave the cockpit during stiff turbulence/Dont have pilots who dont know how to fly a plane in control at any time
SU 593 - Dont let children fly planes/This one speaks for itself
WT 2120 - Dont fly planes with under inflated tires/Dont be bullied into rushing to fly a non-airworthy plane
UA 585/US 427 - The PCU unit on some 737's could stop working and even work in reverse/New design needed
CO 2574 - Dont change shifts in the middle of maintenance without proper notes/Put all screws back in the plane that you take out
ET 409 - Make sure pilots properly rested before flying/Dont allow pilots to take 5 days off in two months only.

cvgComair wrote:

BravoOne wrote:

skymiler wrote:

Air Canada 797 at CVG.

I lost a friend in that tragedy, but every time I hear the announcement for the emergency lights (which is up to 150+ times a year) I am grateful that the loss of his life was not in vain.

Air Canada 797???????

That was the flight number.

Okay, thanks

Air New Zealand flight over Antartica that flew into the side of the volcano or mountain..didnt that produce the ground proximity warning, or was that already in place?

Agree with all that this is a great topic that is rooted in fact rather than fanboy speculation. I'm surprised this hasn't been mentioned yet, but the Tenerife disaster led to many improvements and highlighted how isolated events can add up to something fatal:

CRM--KL's Captain van Zanten was in a rush to get the aircraft to Gran Canaria and return to AMS before the crew timed out. FO and FE both voiced concerns at different times that not everything appeared as it should and were dismissed.
Nonstandard language--both from KL and the tower when KL was at the threshold of the runway.
Chain linked events--first the bomb explosion at Gran Canaria's airport, then KL's decision to refuel the aircraft at TFN and in turn making it much heavier, van Zanten's impatience, the fact that only two ATCers were on duty and listening to a soccer match, an over crowded air field, the last minute fog that rolled in that severely limited visability for all parties involved, radio interference from the tower and PA talking at the same time that in turn meant KL never realized that PA was still on the runway.

There were a lot of things that went wrong that day that in isolation might have had no consequence, but thankfully this disaster led to several improvements including better CRM, better codified language, and with time better runway control/lighting, among other things that have undoubtedly saved lives since.

Some time ago, I tried to collect aircraft accidents which certainly did not change aviation.

Because their causes were just plain stupid, and already covered by existing regulations or training programmes.

For example, on an airport in Western Africa, some pilots used a 737 to practice rejected take-offs. They did so without properly cooling the brakes down...

...well, the plane burned down.

Here's the thread: viewtopic.php?t=598945

David

I think the Turkish DC-10 crash also pointed out that the blowout panels in the passenger floor were sized based on a narrow body (DC-8 707) cargo door blowout. Due to the pressure difference, when the door blew the floor collapsed jamming the cables to the tail from the cockpit. Afterwards, the panels were greatly enlarged.

Jim

Surprised it hasn't been mentioned yet: Colgan Air 3407 caused the minimum hour requirement for a part 121 first officer to rise from 250 to 1500 and also required the new FO's to have an ATP licence as well.

BA 9: What volcanoes can do to aircraft
AF 90: New de-icing procedures
Af 4590: Sadly, it killed the Concorde

SAA 74M off Mauritius. Was key in south Africa as I recall.
Saudia tristar at riyadh was a lesson in how to get everyone safely down only to perish in a burning plane waiting for someone else to do something.

Air Canada DC-9 that caught fire in flight and landed at CVG. A lot of passengers died because they could not find their way to the emergency exits in the smoke. That led to lighting the cabin floor to the exits.

Colgan 3407. Produced new rest regs- FAR 117 and minimum flight hours for hiring (although IMHO neither has really done anything to really mitigate fatigue and crew inexperience.)

Air Ontario (I think it was) F28 at Dryden Ontario. Highlighted the importance of de-icing. Significant change in our world.

Surprised no one has mentioned PA 214 (the "Elkton disaster") - so called because PA 214 was holding overhead on its way into PHL. Long story short, the 707 involved was struck by lightning in a storm and the fuel tanks ignited. Future aircraft manufacturing changed forever as a result of this crash in order to better "lightning proof" engines/fuel from the damage.

I am surprised that nobody has mentioned the Michelin "Near Zero Growth" tyre which was developed to replace the Concorde tyre which was so vulnerable to FOD damage in the July 2000 crash. This type of tyre has been fitted to a variety of aircraft including the A380, A350, A320 neo and 737 MAX.

BravoOne wrote:

skymiler wrote:

Air Canada 797 at CVG.

I lost a friend in that tragedy, but every time I hear the announcement for the emergency lights (which is up to 150+ times a year) I am grateful that the loss of his life was not in vain.

Air Canada 797???????

that was the flight number

UA 266 Jan 18, 1969, 4 minutes after takeoff from LAX. B727 was dispatched with one generator inop. Acft lost an engine on climb, then the 3rd generator shut down, shutting off all power to instruments. The crew could not find the backup power switch in the darkness and became disoriented over the ocean. I believe this incident saw the change to auto-battery backup on subsequent designs.

I don't that's the exact way it happened but you are close enough.

The Lauda Air 767 crash over Thailand that mandated the non deployment of thrust reversers while in flight.

The crash of Air Florida flight 90 led to the development of Type IV deicing fluid.

airmagnac wrote:

- from : a colleague in the systems department

Go back to your pipes... [/quote]

And harnesses. Horrible things, those. Including for the structures guys

By the way :
TWA800 : introduction of the concept of Electrical Wiring Interconnection System (EWIS) to establish an integrated supervision of the design & maintenance of electrical wires, and tightening of rules specifying co-routing, segregation and protection of wires.
Also drove the requirement for reduction of flammability of fuel tanks, usually carried out by inerting the internal air with nitrogen.
I guess the FBI and NTSB reviewed some of their protocols, too...Oh, and don't mention the CIA in an investigation, even if they do have sophisticated animation techniques

Palm 90 reminds me of how many things could have gone wrong (wrong assumptions, kluge-like behaviors, etc.) in a single event.

Reverse thrusters on a icy and snowy ramp, trying to use engine exhaust from the plane in front of you to blow snow off your wings, not recognizing additional buildup of snow on the wings, not rejecting takeoff, failing to engage anti-ice.

Train wreck all around.

I'd also toss in AA 4184 which basically got the ATR 42/72 removed from snow-prone environments for a lot of years.

klwright69 wrote:

I forgot.... The accident where the Brazilian airliner ran off the runway in Sao Paolo and killed everyone.

Not Sao Paolo (Italian?!). It's São Paulo.

Can't really say that TAM 3054 changed aviation... many things were neglected in that accident.
Failure from the crew for not executing a proper go around... they had moderate rain, a relatively short and slippery runway and an inop reverse thrust in one of the engines...
This case did happen before with other A320. Philippine Airlines flight 137 was very similar.