British Airways Flight 38

"BA38" redirects here. For the region of the human brain, see Brodmann area 38.

British Airways Flight 38

G-YMMM after the crash at Heathrow Airport.
Accident summary
Date	17 January 2008 (2008-01-17)
Type	Fuel starvation caused by ice, Landed short of runway
Site	London Heathrow Airport, United Kingdom
Passengers	136
Crew	16
Injuries	47
Fatalities	0
Survivors	152 (all)
Aircraft type	Boeing 777-236ER
Operator	British Airways
Tail number	G-YMMM
Flight origin	Beijing Capital International Airport, People's Republic of China
Destination	London Heathrow Airport, United Kingdom

British Airways Flight 38 (call sign Speedbird 38) was a scheduled flight from Beijing Capital International Airport which crash landed just short of the runway at its destination, London Heathrow Airport, on 17 January 2008 after an 8,100-kilometre (4,400 nmi; 5,000 mi) flight. There were no fatalities, but 47 people sustained injuries.^[1] It was the first accident that resulted in a Boeing 777 hull loss.^[2]

The cause was determined to have been ice crystals in the fuel clogging the fuel-oil heat exchanger (FOHE) of each engine. This restricted fuel flow to the engines as thrust was demanded during the final approach to Heathrow.^[3] Boeing identified the problem as specific to the Rolls-Royce engine fuel-oil heat exchangers, and Rolls-Royce has subsequently developed a modification to its FOHE; the European Aviation Safety Agency (EASA) mandated that all affected aircraft were to be fitted with the modification before 1 January 2011.^[1][4] Boeing 777 aircraft powered by GE or Pratt & Whitney engines were not affected by the problem.^[4]

Accident

The Trent 800 engines aboard Boeing 777-236ER aircraft G-YMMM (manufacturer's serial number 30314, line number 342)^[5] repeatedly failed to respond to a demand for increased thrust from both autothrottle and from manual intervention at 720 feet (220 m) and 2 miles (3.2 km) from touchdown. In attempting to maintain the instrument landing system (ILS) glide slope, the autopilot sacrificed speed, reducing airspeed to 108 knots at 200 feet (61 m).^[6] The plane passed approximately 6 metres (20 ft) above passing cars on the A30 and the airport's Southern Perimeter road. It also passed near a car which had just dropped off the then British Prime Minister, Gordon Brown.^[7] The captain declared an emergency to the control tower 3 seconds before landing.^[1]

The autopilot disconnected at 175 feet (53 m) and the aircraft landed on the grass approximately 1,000 feet (300 m) short of runway 27L. During the impact and short ground roll, the nose gear collapsed, the right main gear separated from the aircraft penetrating the central fuel tank and cabin space, and the left main gear was pushed up through the wing. The aircraft came to rest on the threshold markings at the start of the runway. A significant amount of fuel leaked, but there was no fire.^[6] Four crew members and eight passengers received minor injuries, and one passenger received serious injury – concussion and a broken leg.^[6][8]

Captain Peter Burkill said at a press conference that he would not be publicly commenting on the cause of the incident while the Air Accident Investigation Branch (AAIB) investigation was in progress. He revealed that Senior First Officer John Coward was flying the aircraft at the time and that another First Officer was also present, later identified as Conor Magenis.^[9]

John Coward was more forthcoming in a later interview, stating –

"As the final approach started I became aware that there was no power."^[10]

"Suddenly there was nothing from any of the engines, and the plane started to glide."^[10]

The 150-tonne aircraft was the first Boeing 777 to be written off in the model's 12-year history.^[2][11]

Speculation

Initial theories about the cause focused on a few areas. Although both engines failed to produce increased power when demanded, mechanical engine failure was not regarded as a likely cause given the very low probability of a simultaneous dual engine failure, and was ruled out by the findings of the February Special Bulletin.^[6][12]

Boeing 777-236ER (G-YMMD), a model similar to the crashed aircraft, taking off from London Heathrow Airport.

One theory was a failure of the software or electronics that controls the engines. A story in The Guardian newspaper on 19 January 2008 quoted an unnamed source as stating that an automated alarm that should have alerted the pilots to the drop in engine power failed to actuate.^[13] A failure in the electronic system of the 777 aircraft was put forward as a possible culprit of the accident. According to a news report, an electronic glitch in the computerised engine-control systems may have disrupted the connection between automated and manual controls and the two jet engines.^[12] However, this was ruled out by the findings of the Special Bulletin. Speculation that radio interference from the Prime Minister's motorcade was responsible for the accident was also eliminated as a cause.^[14]

The second area of speculation, later confirmed as the cause in the official report, centred on the fuel supply. Under a fuel starvation scenario, fuel was available but could not reach the engines. Water or debris in the fuel tanks could have cut off the engines from their supply, resulting in power loss. It was unclear, however, whether a fuel supply issue would have produced simultaneous engine failures or more likely would have produced symptoms in one engine before the other.^[12] However, according to the 24 January update, the engines lost power eight seconds apart—the right engine approximately three seconds after more power was requested, and the left engine eight seconds later. Accumulation of ice in the fuel tanks, clogging fuel supply lines in the final stages of the flight, was the subject of closer scrutiny, and while initially ruled out (as both engines were still producing above-idle but significantly diminished thrust, according to a report), this was, at the time of the 24 January update, being investigated as a possible cause.^[11][15]

David Learmount of Flight International speculated that to land in just 350–400 metres, the aircraft must have been near stalling when it touched down. Dr. Thurai Rahulan and Dr. Guy Gratton, both academics, speculated that the weather conditions made wind shear a possible cause.^[8][16] The METAR in force at the time indicated that the wind was forecast to gust according to ICAO criteria for wind reporting, but was not gusting at the time and wind shear had not been reported.^[17] The possibility of a bird strike was raised, but there were no sightings or radar reports of birds.^[12] Consequently, speculation had focused on electronics and fuel supply issues.^[18] In response to speculation that the cause of the accident was ice in the centre fuel tank, United Airlines and American Airlines took precautionary steps to ensure the quality of the fuel used in their aircraft.^[19]

Initial response

Statements were issued by several organisations affiliated with the airport and airline. Immediately after the crash British Airways released this statement:

"A British Airways Boeing 777 aircraft has been involved in an incident today at Heathrow airport. The aircraft was operating as flight BA38 from Beijing." ^[20]

The London Ambulance Service stated that three fast response cars, nine ambulances and several officers were sent to the scene to assess the casualties. Those injured were taken to the nearby Hillingdon hospital.^[21]

Soon after the crash, the Civil Aviation Authority (CAA) announced that they were aware of the incident and that the "incident will be investigated by the Air Accidents Investigation Branch of the Department for Transport and the CAA is offering assistance to all organisations involved." Initial comment from David Learmount, a Flight International analyst, was that "The aircraft had either a total or severe power loss and this occurred very late in the final approach because the pilot did not have time to tell air traffic control or passengers." ^[22]

Willie Walsh, the British Airways Chief Executive released a statement praising the actions of the "flight and cabin crew [who] did a magnificent job and safely evacuated all of the 136 passengers. The captain of the aircraft is one of our most experienced and has been flying with us for nearly 20 years. Our crew are trained to deal with these situations." ^[23] He also praised the fire, ambulance and police services.

BAA Limited:

“	Incident at Heathrow We can confirm that flight BA38, a Boeing 777 arriving from Beijing, carried out an emergency landing at Heathrow Airport today at 12:42. Heathrow’s emergency services attended the scene and passengers were immediately evacuated and taken to a reception centre at the airport. The Air Accidents Investigation Branch is attending the scene. Heathrow Airport’s southern runway was closed immediately after the incident but has now re-opened for take-offs only. The northern runway is operating for arriving aircraft. Passengers flying from Heathrow today should contact their airline regarding the status of their flight. Some arriving aircraft are being diverted to other airports, this is being done on a flight by flight basis.	”
—BAA Limited , BAA Heathrow Homepage

Aftermath

As a consequence of the emergency services deployment to the accident all flights were halted for a short time. When operations resumed, many long-haul outbound flights were either delayed or cancelled and all short haul flights were cancelled for the rest of the day. Some inbound flights were delayed and 24 flights were diverted to Gatwick, Luton or Stansted, and Heathrow Airport received dispensation from the Department of Transport to operate some night flights.^[8] On the following day (18 January) a total of 113 short haul flights were cancelled due to crews and aircraft being out of position.^[24]

On the afternoon of 20 January 2008, the aircraft was removed from its resting place with two cranes lifting it onto wheeled platforms.^[25]

Captain Burkill and Senior First Officer Coward were grounded for a month following the crash while they were assessed for posttraumatic stress disorder. Five months after the accident, Captain Burkill flew again taking charge of a flight to Montreal, Canada. However, he remained "haunted" by the incident, and took voluntary redundancy from British Airways in August 2009.^[26] In September 2010, it was announced that Burkill was to rejoin British Airways in November 2010. Burkill said "I am delighted that the discussions with British Airways, have come to a mutually, happy conclusion. In my opinion British Airways is the pinnacle of any pilot's career and it is my honour and privilege to be returning to an airline that I joined as a young man."^[27]

Although it is a common practice that airlines discontinue a flight number after a crash, British Airways continues to use the Flight 38 designation on its Beijing to London (Heathrow) route. It now uses a 747 instead of a 777.^{[citation needed]}

Awards

All sixteen crew were awarded the BA Safety Medal for their performance during the accident. The medal is British Airways' highest honour.^[28] On 11 December 2008, the crew of BA038 were awarded the President's Award by the Royal Aeronautical Society.^[29] Captain Burkill subsequently established a blog and wrote a book, "Thirty Seconds to Impact" that denounced BA's treatment of the situation following the crash.^[30]

Investigation

The Air Accidents Investigation Branch (AAIB) investigated the accident, with the U.S. National Transportation Safety Board (NTSB), Boeing and Rolls-Royce also participating.^[1] The investigation took two years to complete. A number of preliminary reports and safety recommendations were issued during the course of the investigation, and the AAIB published its final report on 9 February 2010.

An aircraft enthusiast who took photographs of the aircraft on its approach from approximately 100 feet (30 m), released them to the air accident investigators.^[31]

Initial report, 18 January 2008

A map showing the location of the plane (blue dot) after landing and sliding through the field on the runway safety area – route marked in red.

The AAIB released an initial report on 18 January, which stated:^[32]

“	Initial indications from the interviews and Flight Recorder analyses show the flight and approach to have progressed normally until the aircraft was established on late finals for Runway 27L. At approximately 600 ft and 2 miles from touch down, the Autothrottle demanded an increase in thrust from the two engines but the engines did not respond. Following further demands for increased thrust from the Autothrottle, and subsequently the flight crew moving the throttle levers, the engines similarly failed to respond. The aircraft speed reduced and the aircraft descended onto the grass short of the paved runway surface.	”
—AAIB , Accident to Boeing 777–236, G-YMMM at London Heathrow Airport on 17 January 2008 – Initial Report[dead link]

Initial report update, 24 January 2008

An update was issued on 24 January:^[11]

“	As previously reported, whilst the aircraft was stabilised on an ILS approach with the autopilot engaged, the autothrust system commanded an increase in thrust from both engines. The engines both initially responded but after about 3 seconds the thrust of the right engine reduced. Some eight seconds later the thrust reduced on the left engine to a similar level. The engines did not shut down and both engines continued to produce thrust at an engine speed above flight idle, but less than the commanded thrust. Recorded data indicates that an adequate fuel quantity was on board the aircraft and that the autothrottle and engine control commands were performing as expected prior to, and after, the reduction in thrust. All possible scenarios that could explain the thrust reduction and continued lack of response of the engines to throttle lever inputs are being examined, in close cooperation with Boeing, Rolls Royce and British Airways. This work includes a detailed analysis and examination of the complete fuel flow path from the aircraft tanks to the engine fuel nozzles.	”
—AAIB , Accident to Boeing 777–236, G-YMMM at London Heathrow Airport on 17 January 2008 – Initial Report Update[dead link]

Special Bulletin, 18 February 2008

A further update, issued on 18 February, stated that there was "no evidence of a mechanical defect or ingestion of birds or ice", that there was "no evidence of fuel contamination or unusual levels of water content" within the fuel and that the recorded data indicated that there were "no anomalies in the major aircraft systems". Some small foreign bodies, however, were detected in the fuel tanks and these were to undergo further analysis.

The report noted evidence that cavitation had taken place in both high pressure fuel pumps, which could be indicative of a restriction in the fuel supply or excessive aeration of the fuel, although the manufacturer assessed both pumps as still being able to deliver full fuel flow. The report noted the aircraft had flown through air that was unusually cold (but not exceptionally so), and concluded that the temperature had not been low enough to freeze the fuel. Tests are continuing in an attempt to replicate the damage seen in the fuel pumps and to match this to the data recorded on the flight. A comprehensive examination and analysis is to be conducted on the entire aircraft and engine fuel system including modelling fuel flows taking account of environmental and aerodynamic effects.

The report went on to note that the fire extinguisher handles had been manually deployed by the crew before the fuel shut-off switches. The fire extinguisher handles also have the effect of cutting off power to the fuel switches, meaning that the fuel may continue to flow – a potentially dangerous situation. The report restated a previous Boeing Service Bulletin giving procedural advice that fuel switches should be operated before fire handles. It went on: "This was not causal to the accident but could have had serious consequences in the event of a fire during the evacuation." Indeed, the need to issue Safety Recommendation 2008-009, affecting all 777 airframes which had yet to incorporate the Boeing Service Bulletin (SB 777-28-0025) – as was the case with G-YMMM – was given as the main reason for issuing this special bulletin, well before the accident investigation itself was complete.^[6]

Special Bulletin, 12 May 2008

The AAIB issued a further bulletin on 12 May 2008 which confirmed that the investigation continued to focus on fuel delivery. It stated that "The reduction in thrust on both engines was the result of a reduced fuel flow and all engine parameters after the thrust reduction were consistent with this." The report confirmed that the fuel was of good quality and had a freezing point below the coldest temperatures encountered, appearing to rule out fuel freezing as a cause. As in the aforementioned February bulletin, the report noted cavitation damage to the high pressure fuel pumps of both engines, indicative of abnormally low pressure at the pump inlets. After ruling out fuel freezing or contamination, the investigation now focuses on what caused the low pressure at the pump inlets. "Restrictions in the fuel system between the aircraft fuel tanks and each of the engine HP pumps, resulting in reduced fuel flows, is suspected." The fuel delivery system was being investigated at Boeing, and the engines at manufacturer Rolls Royce in Derby.

The Bulletin specifically ruled out certain other possible causes, stating: "There is no evidence of a wake vortex encounter, a bird strike or core engine icing. There is no evidence of any anomalous behaviour of any of the aircraft or engine systems that suggests electromagnetic interference." ^[33]

British Airways internal investigation

An internal investigation into the accident was conducted by British Airways. The report concluded that the actions of the flight crew prevented a worse outcome than actually occurred. It also concluded that the emergency evacuation alarm was too quiet for some of the cabin crew to hear. This is also being investigated by the AAIB.^[34]

Interim Report, 4 September 2008

The AAIB issued an interim report on 4 September. Offering a tentative conclusion, it stated:^[35]

“	The investigation has shown that fuel to both engines was restricted; most probably due to ice within the fuel feed system. The ice was likely to have formed from water that occurred naturally in the fuel whilst the aircraft operated for a long period, with low fuel flows, in an unusually cold environment; although, G-YMMM was operated within the certified operational envelope at all times.	”
—AAIB , Interim Report – Boeing 777-236ER, G-YMMM

The report detailed the extensive testing performed in an effort to replicate the problem suffered by G-YMMM. This included creating a mock-up of G-YMMM's fuel delivery system, to which water was added to study its freezing properties. After a battery of tests, the AAIB had not yet succeeded in reproducing the suspected icing behaviour, and was undertaking further investigation. Nevertheless, the AAIB believed its testing showed that fuel flow was restricted on G-YMMM and that frozen water in the jet fuel could have caused the restriction, ruling out alternative hypotheses such as a failure of the aircraft's FADEC. The hypothesis favoured in the report was that ice had accreted somewhere downstream of the boost pumps in the wing fuel tanks and upstream of the engine-mounted fuel pumps. Either enough ice had accumulated to cause a blockage at a single point, or ice throughout the fuel lines had become dislodged as fuel flow increased during the landing approach, and the dislodged ice had then formed a blockage somewhere downstream.

Because temperatures in flight had not dropped below the 777's designed operating parameters, the Air Accidents Investigations Branch (AAIB) recommended Boeing and Rolls-Royce take interim measures on Trent 800-powered 777s to reduce the risk of ice restricting fuel delivery.^[35]

The report's finding resulted in three safety recommendations:

“	Safety Recommendation 2008-047 It is recommended that the Federal Aviation Administration and the European Aviation Safety Agency, in conjunction with Boeing and Rolls-Royce, introduce interim measures for the Boeing 777, powered by Trent 800 engines, to reduce the risk of ice formed from water in aviation turbine fuel causing a restriction in the fuel feed system.	”
—AAIB , Interim Report – Boeing 777-236ER, G-YMMM

“	Safety Recommendation 2008-048 It is recommended that the Federal Aviation Administration and the European Aviation Safety Agency should take immediate action to consider the implications of the findings of this investigation on other certificated airframe / engine combinations.	”
—AAIB , Interim Report – Boeing 777-236ER, G-YMMM

“	Safety Recommendation 2008-049 It is recommended that the Federal Aviation Administration and the European Aviation Agency review the current certification requirements to ensure that aircraft and engine fuel systems are tolerant to the potential build up and sudden release of ice in the fuel feed system.	”
—AAIB , Interim Report – Boeing 777-236ER, G-YMMM

The report acknowledged that a redesign of the fuel system would not be practical in the near-term, and suggested two ways to lower the risk of recurrence. One was to use a fuel additive called FSII that prevented water ice from forming down to −40 °C. Western air forces have used FSII for decades, and although it is not widely used in commercial aviation, it is nonetheless approved for the 777. The report also suggested that, because low fuel flows are conducive to ice formation, airlines could make operational changes to lessen the risk of a blockage forming shortly before landing.

Boeing revised the 777 operating procedures to keep such blockages from forming, and revised the procedure to be followed in the event of power loss to take into account the possibility that ice accumulation was the cause.^[3]

Final report, 9 February 2010

The AAIB issued a full report on 9 February 2010. It concluded :

“	The investigation identified that the reduction in thrust was due to restricted fuel flow to both engines. The investigation identified the following probable causal factors that led to the fuel flow restrictions: Accreted ice from within the fuel system released, causing a restriction to the engine fuel flow at the face of the FOHE, on both of the engines. Ice had formed within the fuel system, from water that occurred naturally in the fuel, whilst the aircraft operated with low fuel flows over a long period and the localised fuel temperatures were in an area described as the ‘sticky range’. The FOHE, although compliant with the applicable certification requirements, was shown to be susceptible to restriction when presented with soft ice in a high concentration, with a fuel temperature that is below −10 °C and a fuel flow above flight idle. Certification requirements, with which the aircraft and engine fuel systems had to comply, did not take account of this phenomenon as the risk was unrecognised at that time.	”
—AAIB , Report on the accident to Boeing 777-236ER, G-YMMM, at London Heathrow Airport on 17 January 2008

The AAIB also studied the crashworthiness of the aircraft during the accident sequence. It observed that the main attachment point for the main landing gear (MLG) was the rear spar of the aircraft's wing; because this spar also formed the rear wall of the main fuel tanks, the crash landing caused the tanks to rupture. It was recommended that Boeing redesign the landing gear attachment to reduce the likelihood of fuel loss in similar circumstances. In all, eighteen recommendations were made as a result of the investigation.^[1]

Similar incidents

Laboratory duplication of ice crystals clogging the FOHE on a Rolls-Royce Trent 800 series engine taken from the NTSB report^[3] addressing the incidents of BA Flight 38 and DL Flight 18.

On 26 November 2008, Delta Air Lines Flight 18 from Shanghai to Atlanta experienced an "uncommanded rollback" of one engine while in cruise at 39,000 feet. The crew followed manual recovery procedures and the flight continued without incident. One of the U.S. NTSB investigators who worked on the BA Flight 38 investigation has been making the inquiry into this incident, and any similarity between the two incidents.^[36] The NTSB preliminary report is available.^[37]

In early 2009, Boeing sent an update to aircraft operators, linking the British Airways and Delta Air Lines "uncommanded rollback" incidents, and identifying the problem as specific to the Rolls-Royce engine oil-fuel flow heat exchangers.^[4] Originally, it was thought that other aircraft were not affected by the problem.^[4] However, in March 2009, another similar incident happened with an Airbus A330 powered by a Trent series 700 engine.^[38]

The enquiries resulted in a stronger recommendation from Boeing in February 2009 to avoid icing in fuel lines in extremely cold conditions.^[39]

On 11 March 2009, the National Transportation Safety Board issued urgent safety recommendation SB-09-11 calling for the redesign of the fuel/oil heat exchangers used on Rolls-Royce Trent 800 Series engines. A build-up of ice from water naturally occurring in the fuel had caused a restriction of the flow of fuel to the engines of G-YMMM. Rolls-Royce have already started on redesigning the component, with an in-service date of March 2010 at the latest. All affected engines will be fitted with the redesigned component within six months of its certification.^[40] In May 2010, the Airworthiness Directive was extended to cover the Trent 500 and 700 series engines as well.^[38]

Lawsuit against Boeing

In November 2009, it was announced that 10 passengers were to sue Boeing for the incident. They have lodged a lawsuit with the Circuit Court of Cook County in Illinois, in the United States.^[41] It is reported that each of the ten plaintiffs could receive up to US$1,000,000 (£595,433 at the time) compensation. Boeing is reportedly trying to have the case heard at the High Court in London. The lawsuit alleges that the design of the aircraft was "defective and unreasonably dangerous", that Boeing "breached their duty of care" and also breached their "warranties of merchantability and fitness".^[42]

Dramatization

The story of the disaster was featured on the tenth season of Canadian National Geographic Channel show Mayday (known as Air Emergency in the US, Mayday in Ireland and Canada, and Air Crash Investigation in the UK and the rest of world). The episode is entitled "Heathrow Crash Landing".

See also

	London portal
	Aviation portal

• List of notable accidents and incidents on commercial aircraft
• List of airline flights that required gliding
• Runway safety area
• Air safety

References

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17. ^ EGLL 171220Z 21014KT 180V240 9999 SCT008 BKN010 09/08 Q0997 TEMPO 21018G28KT 4000 RADZ BKN008 – translation here, issued by BAA Heathrow Wunderground.com
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External links

• BBC Photos
• Eyewitness reports
• Charig, Francis (8 February 2008). "My escape from BA038 was damn fun". The Daily Telegraph (London). http://www.telegraph.co.uk/comment/3554728/My-escape-from-BA038-was-damn-fun.html. 
• Accident description at the Aviation Safety Network
• British Airways
• Audio interviews with Capt Peter Burkill on avweb.com: Part 1 (The Crash) and Part 2 (The Aftermath)
• August 2010 edition of Flaps Podcast: Interview with Captain Burkill, where he recounted his experience and its aftermath

Coordinates: 51°27′54″N 0°25′54″W / 51.465°N 0.43167°W / 51.465; -0.43167