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El Al Flight 1862

Aftermath of the disaster.
Accident
Date	4 October 1992
Summary	Engine detachment resulting from metal fatigue
Site	Amsterdam-Zuidoost
Aircraft
Aircraft type	Boeing 747-258F
Operator	El Al
Registration	4X-AXG
Flight origin	JFK Int'l Airport New York City, USA
Stopover	Amsterdam Schiphol Airport  Amsterdam, the Netherlands
Destination	Ben Gurion Int'l Airport  Tel Aviv, Israel
Passengers	1
Crew	3
Fatalities	43 (4 on board, 39 on ground)
Injuries	11 serious, 15 minor (all on ground)
Survivors	0

52°19′8″N 4°58′30″E / 52.31889°N 4.97500°E / 52.31889; 4.97500

On 4 October 1992, El Al Flight 1862, a Boeing 747 cargo plane of the state-run Israeli airline El Al, crashed into the Groeneveen and Klein-Kruitberg flats in the Bijlmermeer (colloquially "Bijlmer") neighbourhood (part of Amsterdam-Zuidoost) of Amsterdam, the Netherlands. For the location in the Bijlmermeer, the crash is known in Dutch as the Bijlmerramp (Bijlmer disaster). A total of 43 people were killed, including the plane's crew of three, a non-revenue passenger in a jump seat, and 39 people on the ground. Many more were injured. This accident remains the deadliest aviation accident to ever occur in the Netherlands.

Fatal flight

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On 4 October 1992, the aircraft, a Boeing 747-258F, registration 4X-AXG, was traveling from John F. Kennedy International Airport to Ben Gurion International Airport and made a stopover at Amsterdam Schiphol Airport. During the flight from New York to Schiphol, three issues were noted: fluctuations in the autopilot speed regulation, problems with the shortwave radio, and fluctuations in the voltage of engine number three, the inboard engine on the right wing.

The jet landed at Schiphol at 2:31 pm local time. New cargo was loaded into the plane; the cargo had been approved by customs authorities, but as was realized later, had not been physically inspected. The aircraft was refueled and the observed issues were repaired, at least provisionally. Captain Yitzhak Fuchs, First Officer Arnon Ohad, and Flight Engineer Gedalya Sofer crewed the aircraft. Anat Solomon, the only passenger on board, was traveling to Tel Aviv to marry an El Al employee. Yitzhak Fuchs was an experienced aviator, having previously flown as a fighter-bomber pilot, flying the De Havilland Mosquito in the late 1950s Israeli Air Force.

Flight and crash

Flight 1862 was scheduled to depart at 5:30 pm, but the flight was delayed until 6:20 pm. At 6:22 pm, Flight 1862 departed from runway 01L on a northerly heading. Once airborne, the plane turned to the right in order to follow the Pampus departure route, aided by the Pampus VOR/DME navigation station.

Soon after the turn, at 6:27 pm, above the Gooimeer, a lake near Amsterdam, a sharp bang was heard while the aircraft was climbing through 1.950 meters (6.500 feet). The two fuse pins on engine number three failed. The engine separated from the right wing of the aircraft, shot forward, damaged the wing flaps, and struck engine number four, which then also separated from the wing. The two engines fell away from the plane, also ripping out a 9 meter (30 foot) stretch of the wing's leading edge. They attracted the attention of some pleasure boaters who had been startled by the loud noise. The boaters notified the Netherlands Coastguard of two objects they had seen falling from the sky. Captain Fuchs made a mayday call to air traffic control (ATC) and indicated that he wanted to return to Schiphol. At 6:28:45 pm, the captain reported: "El Al 1862, lost number three and number four engine, number three and number four engine."

ATC and the flight crew did not yet grasp the severity of the situation. Although the flight crew knew they had lost power to the engines, they did not see that the engines had completely broken off and that the wing had been damaged (in aviation, the term "lost" when dealing with engine failure refers to the engines simply having mechanical issues and ceasing to provide thrust, rather than the engines physically separating from the plane). The outboard engine on the wing of a 747 is visible from the cockpit only with difficulty and the inboard engine on the wing is not visible at all. Given the choices that the captain and crew made following the loss of engine power, the Dutch parliamentary inquiry commission that later studied the crash concluded that the crew did not know that both engines had broken away from the right wing.

On the night of the crash, the landing runway in use at Schiphol was runway 06. Captain Fuchs requested runway 27 for an emergency landing, even though that meant landing with a 21-knot quartering tailwind.

The plane was still too high and close in to land when it circled back to the airport. The captain was forced to continue circling Amsterdam until he could reduce his altitude to that required for a final approach to landing. During the second circle, the captain instructed the first officer to extend the wing flaps. The inboard trailing edge flaps extended, since they were powered by the number one hydraulic system, which was still functioning, but the outboard trailing edge flaps did not extend, because they were powered by the number four hydraulic system, which failed when the number four engine was torn off the wing. That partial flap condition meant that the plane would have a higher pitch attitude than normal, as the plane slowed down. The leading edge flaps (powered by the pneumatic system) extended on the left wing, but not on the right wing, because of the intensive damage sustained when the engines broke off, which had severely disrupted air flow over the wing. That differential configuration caused the left wing to generate significantly more lift than the damaged right wing, especially when the pitch attitude increased as the airspeed decreased. The increased lift on the left side increased the tendency to roll further to the right, both because the right outboard aileron was inoperative and because the captain elected to increase the thrust on the left engines in an attempt to reduce his very high sink rate. As the aircraft slowed, the ability of the remaining controls to counteract the right roll diminished. The captain finally lost all ability to prevent the plane from rolling to the right. The roll reached 90 degrees just before the impact with the apartment houses.

At 6:35:25 pm, the first officer radioed to ATC: "Going down, 1862, going down, going down, copied, going down." In the background, the captain was heard instructing the first officer in Hebrew to raise the flaps and lower the landing gear.

At 6:35 pm local time, the plane turned over in an over-90 degree bank and with a nose-down attitude of about 70 degrees, and took a nosedive into two high-rise apartment complexes in the Bijlmermeer neighborhood, at the corner of a building where the Groeneveen complex met the Klein-Kruitberg complex. The plane exploded and set fire to the building, which partially collapsed inward, destroying dozens of apartments. The cockpit came to rest east of the flats, between the building and the viaduct of Amsterdam Metro Line 53, and the tail snapped off, and was blown back by the force of the explosion.

During the last moments of the flight, the arrival traffic controllers made several desperate attempts to contact the aircraft. The Schiphol arrival controllers work from a closed building at Schiphol-East, not from the control tower. At 6:35:45 pm, however, the control tower reported to the arrival controllers: "Het is gebeurd" (lit., "It has happened", but often meaning "It is over"). At that moment a large smoke plume emitting from the crash scene was visible from the control tower. The plane had disappeared from arrival control radar. The arrival controllers reported that the aircraft had last been located 1,5 kilometers (1 mile) west of Weesp and emergency personnel were sent immediately.

At the time of the crash, two police officers were in the Bijlmermeer checking on a burglary report. They saw the aircraft plummet and immediately sounded an alarm. The first fire trucks and rescue services arrived within a few minutes of the crash. Nearby hospitals were advised to prepare for hundreds of casualties. The flats were partly inhabited by undocumented illegal immigrants, and the death toll would be difficult to estimate in the hours after the crash.

In the days immediately following the disaster, the bodies of the victims and the remains of the plane were recovered from the crash site. The remains of the plane were transported to Schiphol for analysis. The parts were not used by investigators to reconstruct the aircraft.

The aircraft's flight data recorder was recovered from the crash site, with its data intact. Despite intensive search activities to recover the cockpit voice recorder from the wreckage area, the recorder was not found, although El Al employees stated that it had been installed in the aircraft.

Causes

In the event of excessive loads on the Boeing 747 engines or engine pylons, the fuse pins holding the engine nacelle to the wing are designed to fracture cleanly, allowing the engine to fall away from the aircraft without damaging the wing or wing fuel tank. Airliners are generally designed to remain airworthy in the event of an engine failure, so that the plane can be landed safely. Damage to a wing or wing fuel tank can have disastrous consequences. The Netherlands Aviation Safety Board found, however, that the fuse pins had not failed properly, but instead had suffered metal fatigue prior to overload failure. The Safety Board pieced together a probable sequence of events for the loss of engine 3:

1. Gradual failure by fatigue and then overload failure of the inboard mid-spar fuse pin at the inboard thin-walled location.
2. Overload failure of the outer lug of the inboard mid-spar pylon fitting.
3. Overload failure of the outboard mid-spar fuse pin at the outboard thin-walled and fatigue-cracked location.
4. Overload failure of the outboard mid-spar fuse pin at the inboard thin-walled location.

This sequence of consecutive failures caused the inboard engine and pylon to break free. By sheer chance, its trajectory after breaking off the wing caused it to slam into the outboard engine and rip it and its pylon off the wing as well, and serious damage was also inflicted on the leading edge of the right wing. Both loss of hydraulic power and damage to the right wing prevented correct operation of the flaps that Captain Fuchs later tried to extend in flight.

Research indicated that the plane had only managed to maintain level flight at first due to its high air speed (280 knots). The damage to the right wing, resulting in reduced lift, had made it much more difficult to keep the plane level. At 280 knots (520 km/h), there was nevertheless sufficient lift on the right wing to keep the plane aloft. Once the plane had to reduce speed for landing, however, it was doomed; there was too little lift on the right wing to enable stable flight, and the plane banked sharply to the right without any chance of recovery.

The official probable causes were determined to be:

The design and certification of the B-747 pylon was found to be inadequate to provide the required level of safety. Furthermore the system to ensure structural integrity by inspection failed. This ultimately caused – probably initiated by fatigue in the inboard midspar fuse-pin – the no. 3 pylon and engine to separate from the wing in such a way that the no. 4 pylon and engine were torn off, part of the leading edge of the wing was damaged and the use of several systems was lost or limited. This subsequently left the flight crew with very limited control of the airplane. Because of the marginal controllability a safe landing became highly improbable, if not virtually impossible.

Victims

Immediately after the crash, 1,500 people were considered missing. The Dutch government originally estimated a death toll of over 200. In the end, the official death toll stood at 43, including all 4 occupants of the plane (3 crew and 1 non-revenue passenger) and 39 people on the ground, considerably lower than expected. At the time of the crash many potential victims were not at home, possibly because of the pleasant weather on the evening of the crash. Twenty-six people sustained non-fatal injuries; eleven of these were injured seriously enough to require hospital treatment.

Memorial

A memorial, designed by architects Herman Hertzberger and Georges Descombes, was built near the crash site with a listing of all the victims.

Health issues

Mental health care was available after the crash to all affected residents and service personnel. After about a year, however, many residents and service personnel began approaching doctors with physical health complaints, which the affected patients blamed on the El Al crash. Insomnia, chronic respiratory infections, general pain and discomfort, impotence, flatulence, and bowel complaints were all reported. 67% of the affected patients were found to be infected with Mycoplasma, and suffered from symptoms similar to the Gulf War Syndrome or Chronic Fatigue Syndrome-like symptoms.

Dutch officials from government departments of transport and of public health asserted that at the time of the crash it was understood that there were no health risks from any cargo on the plane; Els Borst, minister of public health, stated that "geen extreem giftige, zeer gevaarlijke of radioactieve stoffen" ("no extremely toxic, very dangerous, or radioactive materials") had been on board the plane. However, in October 1993, the nuclear energy research foundation Laka reported that the tail of the plane contained 282 kilograms (622 lb) of depleted uranium as trim weight, as did all Boeing 747s at the time; this was not known during the rescue and recovery process.

It was suggested that studies be undertaken on the symptoms of the affected survivors and service personnel, but for several years these suggestions were ignored on the basis that there was no practical reason to believe in any link between the health complaints of the survivors and the Bijlmer crash site.

In 1997, however, an expert testified in the Israeli Knesset that dangerous products would have been released during combustion of the depleted uranium in the tail of the Boeing 747.

The first studies on the symptoms reported by survivors, performed by the Academisch Medisch Centrum, began in May 1998. The AMC eventually concluded that up to a dozen cases of auto-immune disorders among the survivors could be directly attributed to the crash, and health notices were distributed to doctors throughout the Netherlands requesting that extra attention be paid to symptoms of auto-immune disorder, particularly if the patient had a link with the Bijlmer crash site. Another study, performed by the Rijks Instituut voor Volksgezondheid en Milieuhygiene, concluded that although toxic products had been released at the time of the crash, the added risks of cancer were small, approximately one or two additional cases per ten thousand exposed persons. The RIVM also concluded that the chances of uranium poisoning were minimal.

Cargo

Soon after the disaster it was announced that the El Al Boeing 747 had contained fruit, perfumes, and computer components. Dutch Minister Hanja Maij-Weggen asserted that she was certain that the plane contained no military cargo.

In September 1993, the media reported that the El Al Boeing contained dangerous cargo. Some portion of the cargo proved to be Israeli national defense materials. It was also reported that a third of the cargo had not been physically inspected and that the cargo listings had not been checked.

The survivors' health complaints following the crash increased the number of questions about the cargo.

In 1998 it was publicly revealed by El-Al spokesman Nachman Klieman that 190 liters of dimethyl methylphosphonate, a CWC schedule 2 chemical which, among many other uses, can be used for the synthesis of Sarin nerve gas, had been included in the cargo. Israel stated that the material was non-toxic, was to have been used to test filters that protect against chemical weapons, and that it had been clearly listed on the cargo manifest in accordance with international regulations. The Dutch foreign ministry confirmed that it had already known about the presence of chemicals on the plane. The shipment was from a U.S. chemical plant to the Israel Institute for Biological Research under a U.S. Department of Commerce license. According to the Chemical weapons site CWInfo the quantity involved was "too small for the preparation of a militarily useful quantity of Sarin, but would be consistent with making small quantities for testing detection methods and protective clothing".

Alterations to Boeing aircraft

After the crash investigation, Boeing issued a service directive to all airlines regarding the faulty fuse pins on Boeing 747 aircraft. The 747s had their engines taken off and examined for cracks in the fuse pins. If cracks were present, the fuse pins were to be replaced.

See also

• List of notable accidents and incidents on commercial aircraft
• China Airlines Flight 358 – 29 December 1991 – engines and leading edge slats loss on one wing during takeoff.
• American Airlines Flight 191 – 25 May 1979 – engine and leading edge slats loss on one wing during takeoff.
• Air safety

References

1. NASB final report, page 9
2. "Aviation-savety.net". Avation-savety. Retrieved 6 July 2012.
3. Accident description at the Aviation Safety Network
4. "Two engines separate from the right wing and result in loss of control and crash of Boeing 747 freighter" (PDF). flightsafety.org.
5. ^ "Aircraft accident report 92-11 : El Al Flight 1862 Boeing 747-258F 4X-AXG Bijlmermeer, Amsterdam 4 October 1992" (PDF). Nederlands Aviation Safety Board. 24 February 1994. Archived from the original on 26 June 2008.
6. Aloni, Shlomo. "Last of the fighting 'Wooden Wonders': The DH Mosquito in Israeli service" September/October 1999 article with photo in Air Enthusiast #83.
7. The wind was initially from 40 degrees at 21 kt, and then 50 at 22. Runway 27 is aligned due west.
8. http://www.nlr.nl/id~4823/lang~en.pdf
9. Template:It icon Boeing 747 El Al / Bijlmer Memorial [ Memoriale alle vittime di un disastro aereo ]. Architectour.net. Retrieved on 9 September 2011.
10. http://www.mrld.net/pdfs/descombes.pdf
11. Uijt de Haag P.A. and Smetsers R.C. and Witlox H.W. and Krus H.W. and Eisenga A.H. (28 August 2000). "Evaluating the risk from depleted uranium after the Boeing 747-258F crash in Amsterdam, 1992" (PDF). Journal of Hazardous Materials. 76 (1): 39–58. doi:10.1016/S0304-3894(00)00183-7. PMID 10863013. Retrieved 16 May 2007.
12. Henk van der Keur (May 1999). "Uranium Pollution from the Amsterdam 1992 Plane Crash". Laka Foundation. Retrieved 16 May 2007.
13. "Israel says El Al crash chemical 'non-toxic'". BBC. 2 October 1998. Archived from the original on 18 August 2003. Retrieved 2 July 2006.
14. "Israel says El Al crash chemical 'non-toxic'". BBC. 2 October 1998. Retrieved 2 July 2006.
15. Greenberg, Joel (2 October 1998). "Nerve-Gas Element Was in El Al Plane Lost in 1992 Crash". New York Times. Retrieved 11 October 2007.
16. http://cbwinfo.com/Chemical/Precursors/p3.html

Further reading

• Theo Bean, Een gat in mijn hart: een boek gebaseerd op tekeningen en teksten van kinderen na de vliegramp in de Bijlmermeer van 4 oktober 1992. Zwolle: Waanders, 1993.
• Vincent Dekker, Going down, going down: De ware toedracht van de Bijlmerramp. Amsterdam: Pandora, 1999.
• Een beladen vlucht: eindrapport Bijlmer enquête. Sdu Uitgevers, 1999.
• Pierre Heijboer, Doemvlucht: de verzwegen geheimen van de Bijlmerramp. Utrecht: Het Spectrum, 2002.
• R. J. H. Wanhill and A. Oldersma, Fatigue and Fracture in an Aircraft Engine Pylon, Nationaal Lucht- en Ruimtevaartlaboratorium (NLR TP 96719).
• This event is featured on the National Geographic Channel show Seconds From Disaster.

External links

• "Final Report." (Archive) Netherlands Aviation Safety Board. Originally issued in English, with a Dutch translation to be issued at a later time.
• Corrosion Doctors' entry on El Al Flight 1862
• Photographs of the disaster on AirDisaster.com
• Google Maps view of site
• Pre-disaster photos from Airliners.net
• Air Traffic Control transcript

• cvr 781228. Planecrashinfo.com (4 October 1992). Retrieved on 9 September 2011.

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