Boeing 737-236 series 1, G-BGJL: Main document - Leonardo

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• Appendix 17 - Extractfrom FAA cost benefit analysis • Appendix 18 A and B -AAIB Smokehood trials • Appendix 18 C • Appendix 18 D • Appendix 18 E - Smokehoodphoto 1 • Appendix 18 E - Smokehoodphoto 2 • Appendix 18 E - Smokehoodphoto 3 • Appendix 18 E - Smokehoodphoto 4 • Appendix 18 E - Smokehoodphoto 5 • Appendix 19 - Heat stratificationeffects as seen in forward galley area Operator: British Airtours Aircraft Type: Boeing 737-236 series 1 Nationality: British Registration: G-BGJL Manchester International Airport Place of Accident: Latitude 53° 21' N Longitude 002° 16' W Date and Time: 22 August 1985 at 0613 hrs All times in this report are in UTC SYNOPSIS The accident was notified to the Air Accidents Investigation Branch(AAIB) on the morning of 22 August 1985 and an investigation began that day. The AAIB team comprised Mr D F King (Investigator in Charge), Mr M M Charles (Operations), Mr S W Moss (Engineering,Powerplants), Mr C A Protheroe (Engineering, Fire), Mr E J Trimble(Engineering, Evacuation/Survival), Mr C J Ford (Operations),Mr D J Mearns (Operations), Mr R A Davis (Cockpit Voice Recorder)and Mr P F Sheppard (Flight Data Recorder). At 0612 hrs G-BGJL, carrying 131 passengers and 6 crew on a charterflight to Corfu, began its take-off from runway 24 at Manchesterwith the co-pilot handling. About thirty six seconds later, as the airspeed passed 125 knots, the left engine suffered an uncontained failure, which punctured a wing fuel tank access panel. Fuel leakingfrom the wing ignited and burnt as a large plume of fire trailing directly behind the engine. The crew heard a 'thud', and believing that they had suffered a tyre-burst or bird-strike, abandoned the take-off immediately, intending to clear the runway to the right. They had no indication of fire until 9 seconds later, when the left engine fire warning occurred. After an exchange with Air Traffic Control, during which the fire was confirmed, the commander warned his crew of an evacuation from the right side of the aircraft, by making a
oadcast over the cabin address system, and brought the aircraft to a halt in the entrance to link Delta. As the aircraft turned off, a wind of 7 knots from 250° carried the fire onto and around the rear fuselage. After the aircraft stopped the hull was penetrated rapidly and smoke, possibly with some flame transients, entered the cabin through the aft right door which was opened shortly before the aircraft came to a halt.Subsequently fire developed within the cabin. Despite the prompt attendance of the airport fire service, the aircraft was destroyed and 55 persons on board lost their lives. The cause of the accident was an uncontained failure of the left engine, intitiated by a failure of the No 9 combustor can which had been the subject of a repair. A section of the combustor can,which was ejected forcibly from the engine, struck and fractured an underwing fuel tank access panel. The fire which resulted developed catastrophically, primarily because of adverse orientation of the parked aircraft relative to the wind, even though the wind was light. Major contributory factors were the vulnerability of the wingtank access panels to impact, a lack of any effective provision for fighting major fires inside the aircraft cabin, the vulnerability of the aircraft hull to external fire and the extremely toxic nature of the emissions from the burning interior materials. The major cause of the fatalities was rapid incapacitation due to the inhalation of the dense toxic/irritant smoke atmosphere within the cabin, aggravated by evacuation delays caused by a door malfunction and restricted access to the exits. 1 Factual Information 1.1 History of events (see Appendix 1) The two pilots and four cabin crew, (one male purser and three stewardesses), reported for flight KT28M, Manchester to Corfu,at 0500 hrs on the morning of Thursday 22 August 1985, with ascheduled departure at 0600 hrs. The pilots, the commander (a training captain) and a senior first officer, completed their pre-flight preparation. The purser briefed the cabin crew, allocating their duties before boarding the aircraft. Upon reaching the aircraft, the commander carried out an external check while the co-pilot completed the pre-flight checks on the flight deck. The purser checked the safety equipment in the cabin,which was being prepared for the arrival of the passengers. The aircraft documents on the flight deck were examined and an entry in the technical log (entered on the previous day) relating to slow acceleration of No 1 (left) engine was discussed, the co-pilot having been a member of the crew on that occasion. As there had been no reported problems on the two flights after remedial action had been carried out, the commander signed his acceptance of the aircraft in the technical log. It had been arranged that the co-pilot would fly the aircraft on this sector and a comprehensive discussion of their respective duties and the actions to be taken in the event of an emergency during take-off, before or after V1* (146 knots (kt)),took place between the pilots as part of the "Captain's Briefing". The engines were started by the co-pilot and no abnormalities were observed during the start sequence. The commander requested clearance to taxi at 0608 hrs and, when cleared, taxied the aircraft to the holding point of runway 24 (Appendix 2). The cabin crew carried out the safety equipment demonstration to the passengers,after which the purser reported to the commander that there were129 passengers plus 2 infants, a total of 131 passengers on board.A child and one of the infants were seated on their parents' lapsat the aisle seats of row 10 (10C,10D), the row adjacent to
Page 1 and 2: Boeing 737-236 series 1, G-BGJL: Ma
Page 3: • Appendix 6 figure c) • Append
Page 7 and 8: seconds after the 'thud', 20 second
Page 9 and 10: A third foam tender arrived at the
Page 11 and 12: was on duty for 4 hours 30 minutes,
Page 13 and 14: Duty time: 1.5.3.4 Rear stewardess
Page 15 and 16: Boeing 737 installations differed f
Page 17 and 18: 1.17.2.3) were performed on16 Febru
Page 19 and 20: Each cabin window comprised an asse
Page 21 and 22: which waslocated in a pouch at the
Page 23 and 24: Manchester International Airport, l
Page 25 and 26: For some considerable time prior to
Page 27 and 28: The left hand engine, Serial No P70
Page 29 and 30: originalfracture mechanism. (Append
Page 31 and 32: The left tailplane lower skin panel
Page 33 and 34: sooting and heating reflectedthe de
Page 35 and 36: Inspection of the R1 door confirmed
Page 37 and 38: Of the ten portable oxygen bottles
Page 39 and 40: withwater from the hydrant system:
Page 41 and 42: The decision to open the right over
Page 43 and 44: 1.16 Test and research 1.16.1 Engin
Page 45 and 46: The cabin materials fitted in G-BGJ
Page 47 and 48: hydrocarbonsgenerally have a greate
Page 49 and 50: As a result of their awareness of t
Page 51 and 52: "The dominating factor on human cri
Page 53 and 54: were by far the most cost-beneficia
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Hydrogen Chloride 1000 ppm 10 ppm N
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set to inhale 30 litres/minute at a
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massthe droplets lack sufficient mo
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that known to have occurred on G-BG
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Pratt and Whitney JT8D Operators Co
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"(2) Any circumferential or axial c
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1.17.2.4 Post accident regulatory a
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An amendment issued in December 198
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(a) Passage ways between individual
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they could notsee their hands in fr
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considerably in excess of that requ
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predicament.The crew would have bee
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was on duty for 4 hours 30 minutes,
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inspector/welder it is not possible
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indicates strongly that they were a
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problem, British Airways did not se
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of theidle screw. As discussed in t
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and airframe manufacturers, and the
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the fuselage would have beenlargely
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Some witnesses spoke of the fire pe
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It is not clear precisely how duty-
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strongly, and that this conditionwi
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structural membersin buildings, and
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case will be the upwind (high press
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Access shall be provided from the m
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The combined physical and psycholog
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FAR 25.803 nevertheless requires am
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were below levels estimated to prev
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A comprehensive FAA report 10, publ
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In addition, recent developments by
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The crew of the first RIV to arrive
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probably as good as one can practic
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10 The commander and co-pilot evacu
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39 The manufacturer had advised ope
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61 The aft right door aperture allo
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87 The absence of an escort vehicle
Page 127 and 128:
The major cause of the fatalities w
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4.23 A requirement should be introd
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Boeing 737-236 series 1, G-BGJL: Main document - Leonardo

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