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Aviation History
1967
1967 - 2345.PDF
fLIGHT International, 7 December 1967 935 Stock port Accident Inquiry The inquiry commissioner, Mr Peter H. R. Bristow QC (centre), with the two assessors, Captain Philip Brentnall, BOAC's flight training manager, 707s (left), and Mr William Sturrock, project support manager. Hawker Siddeley (Manchester Division) FUEL STARVATION, affecting No 3 as well as No 4 engine,was the immediate cause of the crash of the BritishMidland Canadair C-4 (DC-4M Argonaut) G-ALHG in Stockport on June 4. The aircraft was approaching Manchester Airport after an inclusive-tour flight from Palma, Majorca. Of the 79 passengers and five crew, 69 passengers and three crew were killed; the surviving crew members were the captain and a stewardess. After the difficulties started, described over the R/T as "a bit of trouble with the r.p.m.," the captain decided, when about seven miles out from runway 24 and in cloud, to overshoot. He was told to turn left and climb, but because of the inability to hold or trim the aircraft straight, or to maintain height, 'HG turned to the right and descended. It lost height in a wide right-hand turn and crashed about six minutes later in an open space in the centre of Stockport. Three contributory factors were mentioned on November 28 in London by Sir Elwyn Jones, QC, the Attorney-General, when he opened the public hearing on behalf of the Crown. The first was what he described as a "major and startling mal- function of the fuel system" which, as the flight-recorder indicated, put No 4 engine out of action and, 20sec later, No 3 engine also, and was the result of a "shortcoming in design." The DC-4M, he said, complied with British air- worthiness requirements in all respects but one. A cross-feed system allowed the fuel to be fed from two or more tanks; this was not permissible according to the requirements unless means were provided to prevent air from entering the system. It was allowed in the case of the DC-4M provided that warning notices were displayed. The cocks controlling the cross-feed, said Sir Elwyn, were badly placed, difficult to move and gave no certain impression of what had been selected. A slight error in their position could lead to random feeding from tanks to engines. Earlier Trouble The second factor, Sir Elwyn said, was a failure to record a fuel malfunction on the same aircraft five days before. This came to light in a statement volunteered by a flight engineer more than four months after the crash. While approaching Palma the co-pilot had pointed out to the captain that two of the fuel-gauge readings were very low; he then cross-fed fuel to the engines from the other tanks. A note had been left in the cockpit before the flight saying that No 4 main tank was under-reading by about 75gal. When a check was made after landing at Palma it was found that there could have ta-n only 24-25gal in No 1 main tank and only 14gal 'n No 4 main tank. "What happened on that occasion," Sir Elwyn said, "showed that, in some way or another, fuel from No 4 main tank was being consumed not only by No 4e n;une, but by at least one other engine ... If no further action had been taken and the aircraft had remained airborne for a few minutes longer, the supply of fuel to No 1 and No 4 engines would have ceased." With cross-feeding, however, ftcre was a danger that both No 3 and No 4 engines might have stopped because of air from an empty tank. No entry wasm "de of mjs incident, if shown to be true, in the technical log. A third factor was tiredness. The captain had had, Sir Elwyn said, "very little" sleep during the previous 24hr and the crew had been on duty for 12hr 55min. This was, however, within the present legislated limits and those specified by the operator. During the last 25min of the flight the captain appeared to have made several errors in repeating messages from ATC and at least one error in an originating message and "showed some signs of hesitancy." The Attorney-General also referred to the way in which a C of A can be renewed before the necessary test flight has been made and reported upon. He asked the inquiry to consider whether it was the duty of the Air Registration Board to see whether a test has been carried out and, if not, whether it is a desirable state of affairs to rely on the operator to make the test "as and when he considers it convenient" and to submit the result of the test "as and when he thinks fit." Sir Elwyn went out of his way to remove the popular idea that charter flights, because they are low-priced, are operated at reduced safety levels. In fact, he said, exactly the same safety standards applied to aircraft operated on charter flights as to those on scheduled services. The main reason for the reduced fares was a guaranteed payment for a full load of passengers, which would not be assured on a scheduled service. Ground tests with another DC-4M had shown that, with a cock only about half an inch from the closed position, cross- feeding from various tanks to various engines was possible. Flight tests had shown that the aircraft could, in ideal circum- stances, have reached Manchester Airport on the two port engines—though there might not have been enough height and speed in reserve to lower the undercarriage. It would have been necessary for success to have feathered No 3 as well as No 4 propellers; in the case of 'HG No 4 propeller had been feathered, but No 3 had not—possibly because the captain may not have been aware that both engines had lost all power. This simulated flight, made by the ARB's chief test pilot and the chief pilot of the operators, BMA, showed that, if the captain was preoccupied with maintaining control, the work to be done by the remaining crew members exceeded the capa- bilities "of the only other minimum flight-crew member." It was also found that, with the non-stretch shoulder harness normally used, the captain could not reach some essential controls. Of the 72 persons who died in the accident, 35 had died from burns, 15 from deceleration injuries and the remainder from head injuries and other causes. Sir Elwyn said that the pathologist who carried out the examinations stressed the large number of leg injuries. In his view they were the result of crushing by a thin outer strengthening bar at the back of the seat in front. This bar, the pathologist considered, was a rrfajor factor in preventing passengers from escaping, or attempting to escape. "Therefore," Sir Elwyn said, "some of the casualties and some of the fatalities might not have taken place were it not for the presence of this structure." Later witnesses gave evidence of the fact that the legs of some passengers were trapped under the seats. The need for training potential rescue workers to deal with air disasters was also mentioned. Vital time was lost in this case because police did not know how
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