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Aviation Accident Analysis: A Case Study

Conference Paper  in  Advances in Intelligent Systems and Computing · July 2018

DOI: 10.1007/978-3-319-60525-8_9

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 Aviation Accident Analysis: A Case Study

M. Shahriari ✉ and M.E. Aydin

( )

Konya Necmettin Erbakan University, Konya, Turkey

{Mshahriari,meaydin}@konya.edu.tr

Abstract. This study is focused on an airplane crash case to analyze and identify
the accident contributing factors. The accident occurred on 27th of December
1991 in a few minutes after a Scandinavian Airlines System plane departed from
Stockholm on a route to Copenhagen, Denmark. It was found that the cause of
this accident is a combination of several factors. Errors can result from ambigu‐
ously written procedures, inadequate training, unexpected operational situations
or individual judgments. Situational awareness, environmental and crew coordi‐
nation factors, as well as shortcomings in pilot technical knowledge, skills and
experience, also can cause incidents. Other mistakes might be the result of
improper airspace design or crew coordination.

Keywords: Airplane crash · Aviation safety · Accident cause analysis

1 Introduction

On 27th of December 1991, an aircraft of model MD-81 operated by Scandinavian

Airlines System (SAS), flight SK 751 departed from Arlanda International Airport in
Stockholm, Sweden, on a route to Copenhagen, Denmark. In a couple of minutes after
the departure both engines failed and the emergency landing had to be made on a field.
Unfortunately, it did not succeed and the aircraft was broken in three pieces on impact
with the ground [1].
The aim of this study is to analyze the accident and identify the sequence of events
and conditions that contributed or caused the crash. This paper is prepared on the basis
of a study carried out at Chalmers University of Technology [2] and a literature survey
as well.

2 Description of the Accident

The day before accident SAS MD-81 plane arrived to Stockholm from Zurich in late
evening hours (around 22.00 h) and was parked at gate overnight with temperatures of
around +1 °C [1]. There were left approximately 2550 kg of fuel in each wing tank. The
next day aircraft was scheduled to leave Stockholm for Copenhagen at 08.30 h. In the
following day, early morning, the temperature had dropped to −0 °C [3]. During the
parking time clear ice had formed on the upper side of the wings.

© Springer International Publishing AG 2018

P. Arezes (ed.), Advances in Safety Management and Human Factors,
Advances in Intelligent Systems and Computing 604, DOI 10.1007/978-3-319-60525-8_9
78 M. Shahriari and M.E. Aydin

Checking routines by the ground crew member did not detect this phenomenon. The
aircraft was fueled with 1400 kg of fuel and de-icing procedure started immediately
before take-off. After de-icing the mechanic didn’t check whether there was any clear
ice on the upper side of the wings, since he had previously found none. The required
preparation was completed and aircraft took-off at 08.47 h from Runway 08 [3].
Already after 5 s captain could hear a humming noise. After 25 s (at 1124 ft height)
the right engine started to surge. Surging occurs when the compressor is no longer able
to compress the incoming air to the pressure obtaining in the engine’s combustion section
and this result in violent air shots in the opposite flow direction [1].
The captain throttled back on the surging engine somewhat, but the surges continued
until the engine stopped delivering thrust after 76 s of flight. When the flight had lasted
65 s the left engine also started to surge, which the pilots did not notice before this engine
also lost thrust. This happened two seconds after the right engine had failed. When both
engines had failed the crew prepared for an emergency landing. When the aircraft was
entirely out of the cloud at a height of 300 to 250 m, a field in the direction of flight was
chosen for an emergency landing. During the approach the aircraft collided with trees
and a major part of the right wing was torn off. The tail of the aircraft struck the ground
first and after the impact the aircraft slid along the ground for 110 m before stopping.
The fuselage was broken into three pieces and no fire broke out. All 129 people on board
survived and most without physical injury. One passenger suffered a disabling back
injury [4]. Figure 1 shows the flight pass of SAS flight 751.

Fig. 1. Illustration of SAS flight 751 flight pass [1]

 Aviation Accident Analysis: A Case Study 79

3 Identification of Root Causes

Modern business aircraft are technological marvels. Utilizing the big screen multifunc‐
tion electronic displays that have replaced the dozens of traditional single purpose
mechanical instruments in the cockpit, “smart” fuel control systems that protect the
engines from exceeding specified temperature or power limits and advanced airfoil
designs, that achieve both high-speed cruise and slow-speed stability, commercial jets
and turboprops have attained an unprecedented level of efficiency and safety. Today,
mechanical problems account for only a fraction of aircraft-related safety incidents.
These developments are welcome news to all which travel by air; but to focus solely
on the machinery of flight is to overlook the most critical safety component. The fact is
that even the most technologically sophisticated commercial jet is only as safe as the
pilots flying it are. Analysts estimate that 70% to 90% of aviation accidents involve some
degree of pilot error.
An airplane is now part of a complex modern technology system, and there are three
aspects combined in safety matters within these systems as shown in Fig. 2. All
combined, had an important influence in the occurrence of the accident.

Fig. 2. Safety matter within complex technology system

The aircraft MD-81 crash can be called a system accident with a chain of different
causes. Here we provide an identification of initiating events and states as causal factors.

3.1 Environment

Weather. The weather conditions on December 27,1991 at the time of departure in

Arlanda airport was intermittent light snow, windy winter morning with the temperature
approximately –0 °C.
80 M. Shahriari and M.E. Aydin

During the rescue operation it was overcast but with no precipitation, with temper‐
atures around 0 °C. The ground was frozen crust with a thin layer of snow.
Icy weather is a matter of life or death for the Federal Aviation Administration. Ten
airline accidents during takeoffs between 1978 and 1997 are attributed to ice forming
on jets. As a result, the FAA established tougher rules for aircraft de-icing on the ground.

Clear Ice. Clear ice that broke off from the wings and caused the damage to the engine
fan stages. It led to engines surges and destruction the engines.
It is well known that clear ice can form on the upper surfaces of wings under condi‐
tions of high atmospheric humidity or rain in combination with greatly chilled wings. It
is also well known that such ice is broken off through movements of the wings on liftoff.
During the flight from Zurich the fuel had become greatly chilled. On landing there
were 2 550 kg of fuel in each wing tank, which represents approx. 60% of the tank
volume. This volume of fuel was enough to chill the upper surfaces of the wings. The
meteorological conditions for the formation of clear ice where almost optimal. The flight
technician who inspected the plane during the night noted that clear ice had already
formed on the wings. In addition, passengers saw during the de-icing that the indication
tufts were not moving and on lift off that ice was coming off the wings. It is clear that
“soft” objects being sucked into the engines initiated the engine damage.

3.2 People and Organization

(a) Reported Incidents

Several cases were reported related with the ice phenomenon on all DC-9 versions
and these events were reported to the authorities, manufacturers and operators.
For instance, after a number of cases where clear ice has been found remaining
on the wings following de-icing, Finnair summarized its experience in a report in
1985, in which the problem of undiscovered, unremoved clear ice was headlined
as “The most difficult systematic threat to flight safety today”.
For supervision, the Scandinavian countries have set up a special supervisory
body, to exercise technical and operational flight supervision on its behalf.
In February 1990 it was noted that SAS had reported active work on “DC-9 Ice
Ingestion” and also was participating in international cooperation in the area. As a
result of this work SAS produced Swedish-language de-icing instructions for winter
operations 1991/92. This was judged by STK to be good basic material for solving
the clear ice problem. STK also made sure that the instructions were used in training.
Some recommendations were made before the accident concerning discovering
clear ice. The manufacturer recommended the installation of warning triangles with
indication tufts on critical wing areas.
(b) Inspection procedures
The problem of clear ice on this aircraft type had been known within SAS since
1985.
In various bulletins over the years the clear ice problem was described in detail
and mentioned that the problem was considered the greatest current threat to flight
 Aviation Accident Analysis: A Case Study 81

safety. But the people responsible for the inspection of the aircraft did not follow
these recommendations.
The people responsible should check the aircraft for any ice or snow that may
affect performance. A visual checks from a ladder or when standing on the ground
is not enough.
(c) Lack of information in training
In the MD-80 STUDY GUIDE that pilots use when training on the MD-80, clear
ice was not mentioned. The computerized self-studies referred to current regula‐
tions in FOM and AOM. These contained no information on the clear ice problem.
After the accident the first officer stated that he had never realized the extent of the
clear ice problem during his training on the MD-80. In the AOM section that deals
with what is termed walk-around inspection there was no special instruction
regarding an ice check before flying. Also if clear ice is formed, the aircraft shall
be inspected after de-icing to ensure that all-clear ice has been removed.
The normal checklist included no special item on ice and snow except for a
point regarding de-icing with the engines running. In the associated expanded
checklist it was stated for this control item only that the time required for the fluid
to work should be verified against a table.
The technical division is responsible for de-icing being carried out correctly. In
the division the clear ice problem was well known and had been dealt with in
training, instructions and technical bulletins. Prior to the winter season, personnel
affected at Arlanda were given training in de-icing.
Here, current instructions and general guidance concerning ice formation and
de-icing had been compiled for personnel affected in Sweden. The de-icing instruc‐
tions, which did not have the status of registered technical documentation, were
used in training and were distributed to technicians and mechanics.
But even that the mechanic responsible for handing-over the aircraft was
appointed by the company in June 1990 and trained in de-icing that autumn, was
not able to report the clear ice formed at the accident.
(d) De-icing procedure
It is ultimately the captain’s responsibility to ensure that de-icing is done with
sufficient care. It is, however, the technical division that must answer for de-icing
being performed and checked. Besides the bulletins issued within the technical
division during the course of the year, training was organized before the start of the
winter season for all personnel concerned. Each mechanic was provided with a
checklist, which specified that he should check whether there was any clear ice by
feeling the wing upper surfaces with his hand.
There were no detailed instructions in defined nomenclature that described
how to check for the presence of clear ice, how the ice should be removed or how
the follow-up check and the report to the captain should be effected. In the
present case it should have been clear to the mechanic that he should check
whether there was any clear ice, since rime had been noted on the underside of
the wings in the tank area. He did perform this examination by climbing up on
a ladder and, with one knee up on the leading edge of the left wing near the
fuselage feel the upper side of the wing with one hand. He could not discover
82 M. Shahriari and M.E. Aydin

any clear ice there and concluded wrongly that there was no clear ice further.
There was ice there, however, on an area which he, with this particular means
of checking, could not reach. To be able to carry out an effective examination
it would have been necessary for the mechanic to go out onto the wing, which
was slippery because of the precipitation.
Since he could not find any clear ice before the de-icing, the mechanic had
no reason, given the instructions in force, to check this again after de-icing had
been carried out.

3.3 Technology
(a) Knowledge of ATR within SAS
At the time of the accident there was no knowledge of ATR (Automatic Thrust
Restoration) within SAS. The pilots were therefore not trained on ATR and infor‐
mation about it was not included in their operational documentation. However, all
the necessary information was given in the aircraft manufacturer’s manuals avail‐
able within the company. Hence ATR was described in manuals which every oper‐
ator is obliged to know. Even though the system was originally developed for use
in special 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. If
the pilots had been informed concerning ATR they would have had more chance
of noticing the changeovers. They would then have been better prepared to take
adequate action. It was a serious deficiency in flight safety that the pilots lacked
knowledge of ATR and its function. It should be noted that in the event of loss of
thrust from one engine during the takeoff phase, ATR must ensure that the ATS
(Auto Throttle System) immediately regulates thrust in the functioning engine. The
ATS always maneuvers the engine throttle levers simultaneously and equally. This
means that ATR initiates increase of an engine thrust and affects the engine that
caused the system to be activated. Therefore there is strong requirement for instruc‐
tions on how pilots are to act in the event of engine surging during takeoff.
(b) The combustion system failure
Nothing has emerged to indicate that the aircraft’s engines before the rotation had
any technical fault that affected the development of engine surging. However, a
manufacturing fault in a weld seam in the aircraft’s main fuel duct to the left engine
contributed to a fuel leak occurring in connection with the engine failure. The course
of the failure was very similar in both engines. Mentioned before sequence of events
will be now stated with more details:
Modern turbofan engines are sensitive to damage to fan blades and outer fan
blade seals. Fan blade damage located on the blades outer tips is particularly critical.
Such damage can at high engine power cause local fan tip stall. The fan tip stalls
can increase and form “rotating cells” in the fan stage which called as continually
rotating fan tip stalls.
The aerodynamic disturbances in the fan stage propagated themselves to the
compressors and caused engine surging. As it was indicated before activated ATS
through the effect of ATR caused an increase in throttle that contributed to the fact
 Aviation Accident Analysis: A Case Study 83

that the surging continued and intensified until the engine finally broke up. The risk
of engine surging as a consequence of damage in the fan stages depends on the
extent and character of the damage.
The surges subjected the engines to aerodynamic and mechanical stresses that
became greater with the increasing engine power. The engine damage indicates that
the stage 1 stators were finally broken up by these stresses and the engine failed.
The increase in engine power also caused the left engine to surge and fail in the
same manner. The impact damage found on the fan blade trailing edges was caused
largely by broken-off stator pieces. The pieces then accompanied the airflow into
the front compressors, causing extensive damage to their front stages. Blades and
guide vanes in the rear parts of the compressors were damaged by pieces struck
loose further forward in the engines.
When the engine compressors failed there was high air pressure and thereby a
copious supply of oxygen. Local high temperatures were generated through friction
between rotating, static and broken-off metal pieces. Titanium alloy pieces were
thus ignited. Through a combination of high temperatures and mechanical load,
holes were made in the engines’ rear compressor cases, which serve, as pressure
vessels for the rear compressors. The pressure and temperature thereby decreased
rapidly, causing the titanium fire to stop spontaneously after the brief break-up
phase.
Thanks to the fire alarm system the first officer has recognized the risk and
initiated the engine fire extinguishing system.
As the further consequence of the engine failure was electrical power failure
that inactivated captain’s Electronic Flight Instrument System presentation that
caused more difficult to steer the aircraft in emergency landing.

3.4 Organizational
Negligent Attitude by SAS. The risk of ingestion of clear ice by the engines of the
aircraft type has been known for many years. As early as 1985 a DC-9-51 suffered serious
engine damage for this reason. On the MD-80 series, the risk is greater due to the
configuration of the wing tanks and the larger engine air intake area. The manufacturer
has therefore over the years taken a number of steps to inform operators of the problem
and has distributed numerous service bulletins intended to reduce the risks.
The problem has thus long been known within SAS. In 1987 the aircraft were
equipped with warning triangles with indication tufts to facilitate the discovery of clear
ice. It was stated that it is the captain’s responsibility to check the presence of snow and
ice which might affect the aircraft’s performance.
In the training of MD-80 pilots the clear ice problem has not been specially dealt
with; nor were there any special written instructions for the pilots’ action if there was a
risk of clear ice. If the pilots had more knowledge and unambiguous instructions, they
would probably have been more alert to the risk of clear ice formation.
Technical personnel were thus familiar with the clear-ice problem through training
and information. In the Board’s view, however, the clear-ice problem as dealt with in
LMH, which is the formal governing document for direct work, had an obscure position
84 M. Shahriari and M.E. Aydin

and lacked detailed instructions on how the check for clear ice should be carried out;
nor was there any follow-up on how the check should be performed in daily practice.
There was no routine for reporting on observations regarding clear ice. Though, the
technician who inspected the aircraft during the night noted the presence of clear ice,
but there was no instructions obliging him to report this to the mechanic who was to
carry out the departure check next morning.
Furthermore, the technical personnel had no access to suitable aids for checking
effectively. To reach the critical area on the upper side of the wing without risking an
accident, either special tools or specially built ladders would have been required. It must
be considered remarkable that the numerous different warning signals on the risks asso‐
ciated with clear ice that have reached SAS over the years have not led to effective action
being taken to ensure that aircraft did not take off with clear ice on their wings.
It is obvious that SAS self-monitoring has been deficient regarding the handling of
the clear-ice problem. It also emerges that the Scandinavian Civil Aviation Supervisory
Agency was not aware of the deficient quality assurance. The Board points out that the
idea of self-monitoring presupposes that the supervisory authority ensures that the
company possesses a well functioning system of quality assurance.

4 Conclusion

The cause of this accident is the combination of several factors, ambiguously written
procedures, inadequate training, unexpected operational situations or individual judg‐
ments. Situational awareness, environmental and crew coordination factors, as well as
shortcomings in pilot technical knowledge, skills and experience, also can cause acci‐
dents. Other mistakes might be the result of improper airspace design or crew coordi‐
nation.
As an initial event, the clear ice formed on the upper surface of the wings was not
detected and de-iced well. The company instruction, procedures and even the equipment
were not sufficient to remove the clear ice from the wing surface. Hence during the take-
off the clear ice was broken off the wings and ingested by the engines and caused damage
the engine fan stages, which led to engine surges and failure. The pilot had no sufficient
knowledge and training to identify the problem and taking the necessary action. Further‐
more, there was no knowledge for applying Automatic Thrust Restoration system (ATR)
within the company (SAS). Therefore it was activated and increased the engine power
without the pilot knowledge. Another contributing cause was poor emergency landing
responses in terms of speed and flap position for approach and landing.
Finally, it may be concluded that unsafe pre-conditions which had been created by
SAS organization in terms of training, instruction, operational procedures etc. were
blamed for pilot and technicians errors and mistakes which led to the crash.
 Aviation Accident Analysis: A Case Study 85

References

1. Federal Aviation Administration (FAA): lessons learnt home, Accident overview. http://
lessonslearned.faa.gov/ll_main.cfm?TabID=3&LLID=29&LLTypeID=2. Accessed 28 Jan
2017
2. Anna, C.J., Mauricio, F.: Incident Analysis - Accident Investigation & Causal explanation,
Case of SAS 751. Chalmers University of Technology (2000, unpublished report)
3. Cockpit Voice Recorder Database: 27 December 1991-SAS 751. https://www.tailstrike.com/
271291.htm. Accessed 28 Jan 2017
4. Swedish Civil Aviation Administration 1993: Air traffic accident on 27 December 1991 at
Gottröra, AB County. Report C 1993:57. http://www.havkom.se/assets/reports/English/
C1993_57e_Gottrora.pdf. Accessed 28 Jan 2017

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