The Tragedy Of British Midland Flight 92 And What We Learned From It

The same aircraft involved in the accident pictured in November 1988.

Oftentimes, when people imagine plane crashes, they think of massive, unpreventable technical failures or dramatic mid-air explosions. But in reality, aircraft tragedies often occur not because of what breaks, but rather what is misunderstood in the heat of the moment. Just even one wrong interpretation can cause the deaths of many. This was the case with British Midland Flight 92, a flight from London to Belfast that ended disastrously due to miscommunication and misidentification, and it led to the deaths of 47 people. Despite the tragedy of this incident, it still represents a turning point for aviation safety and more rigorous pilot training. 

The Flight 

On January 8th, 1989, British Midland Flight 92, a Boeing 737-400, departed London for Belfast, Northern Ireland. On board were 118 passengers–many of them families–and eight crew members. The two pilots, Captain Kevin Hunt and First Officer David McClelland, were both extremely experienced pilots with decades of experience in flying. 

The special thing about this flight was that the new Boeing 737-400 had updated engines and design changes from previous models, and it had only been in service for 85 days. The novel design and a crew unfamiliar with the model soon proved to be a disastrous combo because at around 20:05, as the aircraft was ascending through the air, passengers heard a loud bang and smoke quickly started to enter the plane.

Seeing this, the pilots assumed that the right engine of the plane had failed. In previous models, air conditioning relied on air from the right engine. Since smoke was entering the cabin through the air conditioning system, the pilots believed that the right engine was damaged. So, they throttled it back and shut it down. But they couldn’t be further from the truth.

As it would turn out, in the newer model, the air conditioning system relied on both engines. The engine that had actually suffered damage was the left engine, and it was caused by a fan blade detachment. However, though the cockpit indicators clearly pointed to this, the pilots didn’t know which engine had actually malfunctioned, since many of the gauges were new and not known to the pilots. 

The engine malfunction could have correctly been spotted with the usage of vibration gauges, which are critical instruments that detect and measure a plane’s vibrations. This would’ve easily allowed the pilots to detect which engine was malfunctioning. However, these instruments were a new addition to this model, and as stated before, the pilots were unfamiliar with how to use it. Thus, the vibration gauges were not utilized. With the damaged left engine still running at high power and the perfectly-working right engine shut down, the crew unknowingly committed a fatal mistake. 

The Attempted Landing

As the flight crew approached the East Midlands Airport, which was only 11 miles (18 kilometers) from the aircraft’s position, the malfunctioning left engine began erratically fluctuating in engine power, before finally giving out.

At this point, with more than 11 miles to go until they reached the airport, the aircraft was flying with one failed engine and another engine set to idle. Simply put, it was only a matter of minutes before the plane would meet the ground.

The pilots, realizing this, attempted to glide the aircraft safely to the runway, but it hit a slope next to the highway, just a few miles short of the airport. The plane broke into three large pieces when it crashed. 

The Aftermath and Subsequent Investigation

The wreckage of the airplane, split into three large sections.

Of the 126 people on board, 47 were killed, and 74 sustained serious injuries. The entire cockpit crew survived, and so did the majority of the passengers in the forward and aft sections of the split aircraft. However, the middle section bore the brunt of the impact and collapsed completely. After the victims were treated in the hospitals, and the dead were laid to rest, the Air Accidents Investigation Branch (AAIB), the department branch in the United Kingdom that looks into civil aircraft accidents, started their investigation. Their report revealed the core issue: the shutdown of the wrong engine due to the pilots’ misidentification of the fault. Otherwise, even with the damaged left engine, the plane would’ve made it safely to the airport.

They found multiple causes for why the pilot misidentified which of the engines broke. First, the new Boeing 737-400 had a new engine vibration monitoring system—the vibration gauges—but because the pilots were unfamiliar with these instruments, the pilots didn’t notice the abnormally high vibration on the left engine. In addition, these indicators were small and off to the side, so even if they had known about them, it would’ve been hard to notice. Adding on, because the aircraft was on autopilot, it helped mask some other cues that might’ve directed the pilots to realize which engine was malfunctioning. 

Second, Captain Kevin Hunt and First Officer David McClelland, although both highly experienced, relied mostly on what they felt and saw: smoke, vibrations, and flashes. Combined with their knowledge of the air conditioning systems on older Boeing 737 models, these cues led to them assuming that the right engine was faulty. The pilots had no way of physically looking at the engines, and although the cabin crew had seen smoke and flames come from the left engine, they failed to inform the pilots.

In general, for the pilots, there was a huge lack of familiarity with the new aircraft version. Flight 92 was among the first to operate the 737-400, which differed a lot from the older models. The AAIB found that the conversion training for crews transitioning to the newer plane models was often minimal, at only 2 hours long. Therefore, because the crew members were unfamiliar with how the plane operated, they struggled to detect behavioral differences, which contributed to the misdiagnoses. 

Lessons Learned 

After discussing and analyzing these reports, the AAIB made several key changes in the a aviation industry to increase both passenger and crew member safety. First, seeing that the misdiagnosis was caused by a lack of pilot familiarity with the new Boeing model, they ensured that pilot transition training was more rigorous. Now, pilots train extensively on model-specific systems, including engine behavior, instrumentation layout, and handling abnormal situations.

Second, the design and placement of the vibration gauges and failure indicators were changed in future 737 models. Because the pilots didn’t recognize the vibration gauges due to their small size and obscure location, the instruments were made to be larger, more intuitive, and centralized to reduce misinterpretation

Furthermore, this event also added energy to the industry shift toward glass cockpits that included integrated electronic displays rather than needle gauges. This helped better alert pilots to system failures.

Lastly, Flight 92 reinforced the importance of Crew Resource Management (CRM) and cross-verification of decisions. Instead of immediately acting on impulse and assumptions, pilots are now trained to pause and confirm important decisions. Cockpit voice recordings showed that Captain Hunt acted quickly and efficiently, but he didn’t involve the First Officer in troubleshooting before shutting down the right engine. 

Because of this, international airline standards require collaborative diagnoses, where both pilots have to double-check decisions and data before critical actions. 

Conclusion

The crash of British Midland Flight 92 shows that plane crashes aren't always caused by a major component failure. Rather, they are sometimes created by confusion, haste, and a chain of small, preventable errors. However, on the good side, this tragedy created change within the airline industry. Because of this flight, cockpit instruments became easier to read and understand, pilots and crew members were trained more thoroughly, and communication among crew members became more stressed. Though 47 lives were lost in this tragedy, the legacy of Flight 92 remains in every safe flight today.