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were trying to get ready for descent and landing, they were also in receipt of regular
communications from ATC, had to talk to the operating company (BMA), keep the
passengers informed of the situation, and complete the appropriate checklist in
preparation for landing with one engine. The problem was made worse by the fact
that the First Officer struggled to reprogram the Flight Management System (FMS)
successfully with the details needed for landing at East Midlands airport. The way
they had to use the FMS was unusual and rarely practiced. This is another area where
the lack of appropriate recurrent training contributed to the accident.
Flight Crew Level Issues
During the flight the pilots announced to the crew and passengers that there had
been some trouble with the right engine but it had now been shut down. While
some passengers could see the evidence of an engine fire, they did not inform the
pilots that they had shut down the wrong engine. This appears to be an example of
the problem of social distance, where the passengers perceive the pilots as being
highly trained professionals, so they must know what they are doing, which means
that the passengers do not feel in a position to correct them. The smell of smoke
had dissipated by the time the announcement was made, too, which may also have
had an influence on the passengers' thinking.
Three members of the cabin crew also reported having seen evidence of the fire
in the #1 engine but they did not report this to the pilots. This seems to have been a
failure in what is called Crew Resource Management, a procedure designed to
ensure that all the members of a flight crew (pilots and cabin crew) communicate
with one another and work together as a team. So the cabin crew should not have
felt that there was a large social distance between them and the pilots, and should
have not felt intimidated about telling the pilots about what they had seen even
though it appeared to contradict what the pilots had said. This could have been
attributed to a lack of CRM training.
Cockpit Level Issues
The first indication that there was a problem with the engines came when the flight
crew felt excessive vibrations in the aircraft and detected smoke in the cockpit.
When both pilots were interviewed after the accident, neither could recall having
seen any indication of the abnormally high vibration levels on the Engine
Instrument System (EIS). The Captain noted that he rarely scanned the vibration
gauges because he had found them to be unreliable in other aircraft in the past.
Experts, like pilots, have a highly developed mental model of the world in which
they normally operate, and this helps them to perform the tasks they are supposed
to. In pilots, this mental model will help guide where they need to look to find
appropriate information about the current state of the aircraft. In this case, the
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