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Scandinavian Airlines Flight 751
OY-KHO, the aircraft involved in the crash.
Accident
Date27 December 1991
SummaryDual engine failure due to foreign object damage[1]
SiteGottröra, Norrtälje Municipality, Sweden
59°46′06″N 018°07′55″E / 59.76833°N 18.13194°E / 59.76833; 18.13194Coordinates: 59°46′06″N 018°07′55″E / 59.76833°N 18.13194°E / 59.76833; 18.13194
Aircraft
Aircraft typeMcDonnell Douglas MD-81
Aircraft nameDana Viking
OperatorScandinavian Airlines System
RegistrationOY-KHO
Flight originStockholm Arlanda Airport
StopoverCopenhagen Airport
DestinationWarsaw Chopin Airport
Occupants129
Passengers123
Crew6
Fatalities0
Injuries92 (8 serious, 84 minor)
Survivors129

Scandinavian Airlines Flight 751 was a regularly scheduled Scandinavian Airlines passenger flight from Stockholm, Sweden, to Warsaw, Poland, via Copenhagen, Denmark. On 27 December 1991, a McDonnell Douglas MD-81 operating the flight, registration OY-KHO, piloted by Danish Captain Stefan G. Rasmussen (44) and Swedish first officer Ulf Cedermark (34), both experienced pilots with 8,000 and 3,000 flight hours, respectively, was forced to make an emergency landing in a field near Gottröra, Sweden. Ice had collected on the wings' inner roots (close to the fuselage) before takeoff, broke off, and was ingested into the engines as the aircraft became airborne on takeoff, ultimately resulting in the failure of both engines. All 129 passengers and crew aboard survived.

The incident is known as the Gottröra crash (Swedish: Gottrörakraschen) or the Miracle at Gottröra (Swedish: Miraklet i Gottröra) in Sweden.[2][3]

Aircraft

The aircraft was a McDonnell Douglas MD-81, registered OY-KHO with serial number 53003, line number 1844. It made its first flight on 16 March 1991, and was delivered soon after to SAS on 10 April 1991. At the time of the accident, the aircraft had been in service for only nine months. It was fitted with two Pratt & Whitney JT8D low-bypass turbofan engines.[4]

Accident

The aircraft had arrived at Stockholm-Arlanda Airport at 22:09 local time after a flight from Zürich the previous evening and was parked overnight at temperatures of around 0 to 1 °C (32 to 34 °F). About 2,550 kilograms (5,620 lb) of very cold, flight-chilled fuel remained in the wing tanks. Due to this, clear ice had formed on the upper side of the wings, but was not detected. The aircraft was de-iced with 850 litres (190 imp gal; 220 US gal) of de-icing fluid, but not checked afterwards for remaining ice by the de-icing personnel or the Pilot-in-Charge, Captain Rasmussen, which he was required to do by the Scandinavian Airlines "Flight Deck Bulletin/Winterization" given to pilots.[5]

The plane departed from Stockholm at 08:47. Shortly after liftoff, pieces of ice broke off and slammed into the fans of both engines, deforming the fan blades sufficiently to disturb the airflow to the compressors. The disturbed airflow caused the compressors to stall and this in turn caused the engines to surge. As the engines were not throttled down sufficiently, the surges continued. The high loads from repeated engine surges quickly led to the breakup of both engines.

From the pilots' point of view, after 25 seconds of flight, noises and vibrations caused by the No. 2 engine surging were first noticed. The flight crew responded by throttling down a little, but an automatic system, ATR (automatic thrust restoration), that had not been described to the flight crew by SAS, simultaneously increased throttle as a response to the asymmetric engine power and reduced climb rate. As a consequence, the engine surges continued. SAS Flight Captain Per Holmberg, who was on board as a passenger, noticed the problems early and hurried to the cockpit to assist the crew. Engine No. 1 surged 39 seconds later and both engines failed at 76 and 78 seconds, respectively, into flight, at an altitude of 3,220 ft (980 m).

The pilot responded to the loss of both engines by pitching the aircraft down in a dive before leveling it, to try to have it glide the longest possible distance without stalling. The pilots requested a return to Arlanda and attempted the restart procedure,[6] but, with the aircraft emerging from cloud cover at 890 ft (270 m) altitude, they chose a field in the forest, near the Vängsjöberg seat farm in Gottröra, Uppland, for an immediate emergency landing.

During the final descent, the aircraft hit several trees, losing a large part of the right wing. It struck the ground tail-first, and the tail cone of the plane broke off. The plane slid across the field for 110 metres (360 ft), during which the main landing gear of the plane dug marks into the field and sheared off, the nose landing gear broke off, and the fuselage broke into three parts. As a result of the accident, 25 people were injured—two of them seriously—but there were no fatalities. The flight attendants had instructed passengers to adopt the brace position, which is credited with the lack of fatalities.[7]

The flight crew, and especially Captain Rasmussen, were lauded for the skilled emergency landing in a fast-developing, potentially fatal situation. Rasmussen commented that "few civilian air pilots are ever put to a test of the skills they have acquired during training to this degree".[citation needed] He said he was proud of his crew and very relieved everyone had survived. He chose not to return to piloting commercial aircraft.

Scandinavian Airlines continues to use flight number 751 for its Copenhagen-to-Warsaw route.[8]

Investigation and recommendations

According to the official accident report by the Swedish Accident Investigation Board (SHK), the problem of clear ice formation on the wings in this type of aircraft was a well-known phenomenon at the time of the accident. From 1985 onward, McDonnell Douglas gave extensive information, including several "All Operators Letters" that dealt with the clear ice problem. In the "All Operators Letter" of 14 October 1986, operators were informed of how the Finnish airline Finnair had solved the problem of discovering clear ice. In 1988 and 1989, McDonnell Douglas arranged "Theme Conferences" dealing with clear ice formation. SAS took part in these conferences.[5]:61

On 26 October 1991, SAS distributed a "Flight Deck Bulletin/Winterization" to all pilots. It stated: "It is the Pilot-in-Charge's responsibility to check the aircraft for any ice or snow that may affect performance" and in the section "Clear Ice", it noted " [a]lthough the awareness within Line Maintenance is mostly good, the responsibility again rests with the Pilot-in-Charge that the aircraft is physically checked by means of a hands-on check on the upper side of the wing. A visual check from a ladder or when standing on the ground is not enough".[5]

Another contribution to the accident was insufficient training of the crew; they were not trained in restoring engine operation after they repeatedly surged. There was no simulator or other training on the engine surging problem. Secondly, they were not informed about a pre-installed automatic thrust system (automatic thrust restoration or ATR). The reason for this lapse of information was that there was no knowledge of ATR within SAS. However, ATR was described in manuals by the aircraft manufacturer which every operator is obliged to know. Even though the system was developed for use in procedures not applied by SAS, a sufficiently careful study of the manuals should have led to SAS noting the system and training its pilots in its function.[5]

The conclusion of the official accident report stated:

Contributary causes were:

In the section "Compressor Failures", the report stated:

However, the newly installed ATR prevented the pilots from successfully performing the normal remedial measure to halt compressor stall, i.e., throttling back the engines, as the ATR system – designed to prevent pilots from using less than normal thrust when climbing out after take-off for noise abatement reasons – restored engine take-off power throttle settings, contrary to the pilots' reduced throttle commands. This damaged the engines, until eventually, they failed completely removing any possibility of a crash-avoiding restart. The ATR system designed for safety forced the plane into a crash landing with no other options. This use of a safety system meant to operate in spite of and independent from any cockpit controls would rear its ugly head again in 2018 when an MCAS (Maneuvering Characteritics Augmentation System) system was installed in Boeing's new 737 Max. Similar in design, it was meant to prevent the plane from ever stalling and would act against the actions of the pilot so that even when the computer mistakenly thought it was stalling would force the plane to the ground rendering the pilots powerless against it. This hidden "safety system" was responsible for two major crashes and 346 deaths.[9]

In popular culture

The story of the accident was featured on the tenth season of the Canadian TV series Mayday. The episode is entitled "Pilot Betrayed."[10]

See also

References

  1. ^ http://lessonslearned.faa.gov/ll_main.cfm?TabID=3&LLID=29&LLTypeID=2
  2. ^ "Gottrörakraschen" [The Gottröra Crash]. P3 Dokumentär (in Swedish). 4 May 2008. Sveriges Radio. P3. Retrieved 25 August 2020.
  3. ^ "Miraklet i Gottröra rör upp känslorna efter 20 år igen" [The miracle in Gottröra stirs up the emotions again after 20 years]. Expressen (in Swedish). Retrieved 15 February 2017.
  4. ^ "McDonnell Douglas MD-80/90 MSN 53003". Airfleets.net. Retrieved 3 September 2015.
  5. ^ a b c d "Air Traffic Accident on 27 December 1991 at Gottröra, AB county" (PDF) (Official accident report). Report C 1993:57. Case L-124/91. Swedish Accident Investigation Authority. 20 October 1993. Retrieved 3 September 2015.
  6. ^ Cockpit Voice Recorder transcript for SK 751 Hosted at aviation-safety.net
  7. ^ Damski, Anna. "Brace Position". Inflight Safety Page. Retrieved 21 January 2011.
  8. ^ "Flight Radar 24".
  9. ^ https://transportation.house.gov/imo/media/doc/2020.09.15%20FINAL%20737%20MAX%20Report%20for%20Public%20Release.pdf
  10. ^ "Air Emergency" Pilot Betrayed (TV Episode 2011), retrieved 15 February 2017