User:Plmoknijb/Bijlmerramp

El Al Flight 1862
Occurrence
Date	October 4 1992
Summary	Metal fatigue in the fuse pin, engine collision
Site	Amsterdam Zuidoost
Aircraft type	Boeing 747-258F
Operator	El Al
Registration	4X-AXG
Passengers	1
Crew	3
Fatalities	43
Survivors	0 (excluding people on the ground)

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

On October 4, 1992, El Al Flight 1862, a Boeing 747 cargo plane of the Israeli airline El Al, crashed into the Groeneveen and Klein-Kruitberg flats in the Bijlmermeer (colloquially "Bijlmer") neighbourhood (part of Amsterdam Zuidoost) of Amsterdam, Netherlands. A total of 43 people were killed, including the plane's crew of three and a non-revenue passenger in a jumpseat. Many more were injured.

Fatal flight

On October 4, 1992, the plane, a Boeing 747-258F, registration 4X-AXG, was traveling from New York to Tel Aviv and made a stopover at Schiphol. 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 #3.

The jet landed at Schiphol at 14:31 local time. Planespotters in the vicinity noticed that one of the engines appeared to be hanging from the wing in an awkward position.[1] 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 were on board. Anat Solomon, the lone passenger on board, was an El Al employee traveling to Tel Aviv to marry an El Al colleague.

Departure from Schiphol

Flight 1862 was scheduled to depart at 5:30 PM, but departure was postponed till 6:20 PM. At 6:22 PM, Flight 1862 departed from runway 18C/36C (the Zwanenburgbaan) on a northern heading. Once away from the runway, the plane turned to the right in order to follow the so-called Pampus departure route, aided by the Pampus VOR-DME navigation station. Soon after the turn, at 6:27 PM, the crew communicated a first problem to the tower. In the few minutes prior to the call, air traffic control (ATC) had already noticed that the El Al was gaining altitude with some difficulty. But because this is not an uncommon problem for heavy cargo aircraft, it was not a matter of major concern.

Above the Gooimeer, a lake near Amsterdam, a sharp bang rang out. Engine #3 separated from the right wing of the aircraft, damaged the wing flaps, and struck engine #4, which then also separated from the wing. The two engines fell away from the plane. They attracted the attention of some pleasure boaters who had been startled by the loud noise. The boaters notified the Netherlands Coast Guard of two objects they had seen falling from the sky. Captain Fuchs made a mayday call to the control tower and indicated that he wanted to return to Schiphol. A few minutes later, the captain reported: "El Al 1862, lost number 3 and number 4 engine, number 3 and number 4 engine."

ATC did not yet grasp the enormity of the situation. In aviation, the word "lost" as Captain Fuchs used it generally means a loss of engine capacity. ATC therefore believed that two engines had merely flamed out or had otherwise stopped functioning, and did not know that they had actually broken off of the wing. It is probable that the crew, too, did not know that the engines had fallen off the aircraft. The outboard engine on the wing of a 747 is visible from the cockpit only with some 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 would later study the crash assumed that the crew did not know that both engines had broken away from the right wing.

Emergency landing

On the evening of October 4, 1992, the runway available for traffic at Schiphol was runway 06 (the Kaagbaan). However, Captain Fuchs requested runway 27 (the Buitenveldertbaan) for an emergency landing. Why Fuchs made this choice is not clear. Because the wind was from the northeast that evening, the fully loaded plane would have had to land with considerable tailwind. Fuchs may have chosen this runway because he believed that it was the longest available, or because it was the only runway the crew could easily see at the time. Another theory suggests that the crew may have thought that the Israeli plane had been targeted by a surface-to-air missile; El Al operates under strict security due to its politically sensitive position as an Israeli airline. Thus, the captain would have chosen runway 27 because the approach route for this runway crosses over urban area, where the chances of another missile's being fired at the plane would be smaller than if the crew chose an approach route over marshland or pastures.

In order to first dump fuel to remove the plane's excess weight, and then to make a careful approach to the runway, the damaged aircraft navigated a circle above Amsterdam. During this circle the captain gave the first officer the order to extend the wing flaps. The flaps extended on the left wing, but because the falling engines had severely damaged the leading edge of the right wing, the right wing flaps could not be extended. As a result, the left wing experienced more lift than the right. Captain Fuchs, who could not see what had happened to the right wing, informed ATC of a problem with the flaps. Schiphol emergency fire services were positioned along runway 27 in order to immediately extinguish any fires upon landing.

Initially, the aircraft remained under control during its descent to the runway. The moment the plane descended below 1500 feet and reduced speed, it banked sharply to the right and became uncontrollable. Captain Fuchs 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.

Crash

At 6:35 PM local time, the Boeing 747, in nearly a ninety-degree bank with its right wing pointing at the ground, plowed into two high-rise apartment complexes in the Bijlmermeer neighborhood, right at the corner of a building where the Groeneveen complex met the Klein-Kruitberg complex. The building exploded into flames and 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.

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"). At that moment an enormous cloud of smoke was visible above Amsterdam from the control tower. El Al Flight 1862 disappeared from arrival control radar. The arrival controllers reported that the aircraft had last been located 1 mile west of Weesp. Immediately, emergency personnel were sent to Weesp.

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. Hundreds were feared dead. The flats were partly inhabited by undocumented illegal immigrants, and the death toll was 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. Curiously, the parts were not used to reconstruct the aircraft. During the investigation, significant portions of the debris from the plane and the flats were sold as scrap.

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.[2]

This sequence of step-by-step failures caused the engine and nacelle to tilt up and right due to gyroscopic forces and then to finally break free, knocking outboard engine 4 off the wing as well and inflicting serious damage on the leading edge of the right wing, including the control surfaces (flaps) that Captain Fuchs had 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, 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.

A China Airlines 747-200F freighter was brought down by the same causes in December 1991.^{[citation needed]}

Official victim count

Fifteen hundred persons were considered missing immediately after the crash. The Dutch government originally estimated a death toll of over 200. In the end, the official death toll stood at 43, considerably lower than expected. The plane carried only the flight crew and one passenger, and at the time of the crash many potential victims were not at home, possibly thanks to the pleasant weather on the evening of the crash. Twenty-six victims were located. Eleven of these had been taken to hospital.

Rumors have persisted that the actual victim count must have been higher than 43. At very high temperatures such as those encountered after the crash of a jet loaded with fuel, about 1100 degrees Celsius, bodies can be completely incinerated. Nearly a third of the bodies in the 1988 Lockerbie disaster were never recovered.^{[citation needed]} Additionally, the apartment complexes where the El Al flight had crashed contained many undocumented residents, illegal immigrants to the Netherlands. However, the Dutch parliamentary inquiry commission concluded during the investigation that the number of located bodies was more or less commensurate with the final number of missing persons, and that therefore there were no reasons to suspect that the actual death toll was higher than 43.

Health issues

Mental health care was available after the crash to all affected residents and service personnel. After about a year, however, numbers of 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.

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 very toxic, very dangerous or radioactive materials") were on board the plane. However, in October 1993, the nuclear energy research foundation Laka reported that the tail of the plane contained 400 kg of depleted uranium as trim weight, as did all Boeing 747s at the time^{[citation needed]}; however, 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. A Swedish study done on survivors' feces showed elevated quantities of uranium; although the validity of this study was questioned, the result nevertheless caused political upheaval.

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 concerns

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 had indeed 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 only served to increase the number of questions about the cargo.

It was reported that the plane's cargo included, amongst other things: bullets, spare parts for AIM-9 Sidewinder missiles, spare parts for Patriot missiles and 190 litres of dimethyl methylphosphonate.^{[citation needed]}

Dimethyl methylphosphonate is not classified as toxic, but is harmful if inhaled, swallowed or absorbed through the skin. Dimethyl methylphosphonate is primarily used as a flame retardant. It is also used as a pre-ignition additive for gasoline, anti-foaming agent, plasticizer, stabilizer, textile conditioner, antistatic agent, and as an additive for solvents and low-temperature hydraulic fluids. It is also a Chemical Weapons Convention schedule 2 chemical used in the synthesis of sarin nerve gas. The dimethyl methylphosphonate on board the plane was from an American chemical plant and was being sent to the Israel Institute for Biological Research under a United States Department of Commerce license.^{[citation needed]}

"Men in white suits"

In June 1993, the Dutch newspaper Trouw reported that on the morning of Monday, October 5, some twenty persons in white suits were seen at the site of the crash. These persons quickly became the subject of speculation. Witnesses claimed that the white-suited persons did not speak in Dutch and removed evidence from the crash site under white sheets.

The claims of "men in white suits" subsided into obscurity for some years, until 1997, when they became the subject of political attention. In October 1997, Theo Meijer, a Christen Democratisch Appèl member of the Senate, launched an inquiry. Minister Els Borst reported half a year later that there appeared to be no relation between the mysterious persons in white suits and the health complaints of residents at the crash site. Meanwhile, the Rijksrecherche (Netherlands National Police Internal Investigations Department) had begun an investigation into the incident.

In the media emerged further speculations; the Algemeen Dagblad claimed that the white-suited persons had flown in and out of the site in a helicopter. The Trouw reported that they had been seen emerging from vehicles with French license plates. Reports also asserted that there had been extra, secret flights to Israel in the days after the crash. Speculations grew that the El Al Boeing had contained secret military cargo that Israeli Mossad agents were ordered to strip from the crash site.

The Rijksrecherche concluded that the people in white suits were health workers from GGD Amsterdam. However, Israelis had also been seen at the crash site. As a result of these findings and of a parlimentary debate held following the Rijksrecherche's conclusion, the Rijksrecherche received instructions to continue investigations. Several follow-up studies took place, but no clear conclusion was reached. The commission concluded eventually that many of the witness statements simply pertained to rescue workers dressed in light-colored clothing, but it could not explain all of the witness statements. The commission also concluded that evidence had indeed in all probability been removed from the crash site.

Alterations to Boeing aircraft

After the crash investigation, Boeing issued a service directive regarding the faulty fuse pins on Boeing 747 aircraft. ^{[citation needed]}

Memorial

A memorial was constructed near the crash site by architect Herman Hertzberger.

References

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.