British Airtours Flight 28M – The Components of a Disaster

19 Aug 16 4 Comments

When morning broke on the 22nd of August 1985, the crew and passengers of a charter flight to Corfu could have no idea that they were going to make aviation history with one of the worst accidents in Britain. This accident remains in every text book as defining the issues for procedures on the ground and passenger evacuation. The changes to the aviation industry include seating layout fire-resistant seat covers, floor lighting, better access to fire extinguisher, clearer instructions for evacuation and general use of fire resistant materials in the cabins of the aircraft.

Forward section of the aircraft showing left and right escape slides deployed.

The two pilots of the flight crew and four cabin crew reported for duty at Manchester Airport at 0500 hours that morning for flight KT28M from Manchester to Corfu in a Boeing 737.

The captain carried out the external checks while the first officer completed the pre-flight checks on the flight deck and the purser checked the safety equipment in the cabin. They discussed an entry in the technical log from the day before and then the captain signed his acceptance of the aircraft.

The technical log included reports of slow acceleration, slow start and throttle stagger.

Throttle stagger is when the positions of the throttle levers are not matched when achieving the same Engine Pressure Ratio (EPR) for both engines. In this case, the left engine lever was slightly forward of the right engine lever in order to get both engines to the same EPR.

The passengers boarded the aircraft. They were what aircraft crew call the “bucket and spade brigade,” holiday makers without a lot of experience with flying. The 130-seater Boeing 737 was full: there were 129 passengers and two infants for a total of 131 passengers on board.

At 06:08, with the engines started and everything seeming normal, the flight crew requested clearance to taxi.

The senior cabin crew member and another cabin crew member working the front half of the aircraft strapped themselves into their seats on a stowable bench in the left forward galley, facing rearwards.

Once on the runway, the first officer, who was the Pilot Flying, requested take-off power. The captain advanced the throttles in his role as Pilot Monitoring and he commented that the No. 1 engine acceleration was acceptable. The first officer agreed that it was better than on the previous day, when he’d flown in the same aircraft. They selected auto-throttle and the engines achieved take-off power.

At 06:12 the 737 began its take-off run. The captain called out 80 knots, which the first officer confirmed. Twelve seconds later, there was a loud thud.

The captain immediately ordered for the take-off to be aborted, closed the throttles and selected reverse thrust on both engines. The first officer applied maximum wheel braking.

The captain believed that they’d either suffered a bird strike or a burst tyre. They had plenty of runway in front of them and he called out, “Don’t hammer the brakes, don’t hammer the brakes.” The first officer modulated his braking effort.

45 seconds after the start of the take-off run, nine seconds after the thud, as the aircraft decelerated, the captain informed ATC that they were abandoning the take-off.

What the flight crew didn’t know is that the thud had actually come from the engine, not from the tyres nor the result of a bird strike.

The left engine had “suffered an uncontained failure”. The No. 9 combustor can had exploded and shattered into several pieces. A section of the can flew out of the engine and struck the underwing fuel tank access panel.

The fuel leaking from the wing ignited and burnt as a large plume of fire trailing behind the engine.

Each wing tank held 4,590 kg of fuel.

The fire bell on the flight deck started ringing as the captain started speaking and he said, “It looks like we’ve got a fire on number 1,” meaning engine number 1. This was the first indication he had that there was a fire.

ATC responded. “Right, there’s a lot of fire, they’re on their way now.”

The captain asked if he needed to evacuate the passengers and the controller replied, “I would do via the starboard side.”

It was 25 seconds after the thud; twenty seconds before the aircraft stopped.

The Operations Manual for engine malfunctions during take-off advised taxi-ing clear of the runway if possible and added that if there was a fire, consideration should be given to turning into wind before stopping. However, it wasn’t until the radio call that the flight crew understood there was a fire at all. The wind was only seven knots, insignificant from the point of view of handling the aircraft. The crew, and the aviation community, were not yet aware of the critical effects of light winds on fire.

The captain told the crew that they were going to need to evacuate from the right side of the aircraft. The flight crew continued with their plan to evacuate the runway.

This was the first indication to the flight deck drew that the problem could be other than a tyre burst or bird strike. It is evident that this new and conflicting information could not easily have been reconciled with either, except perhaps as a result of secondary damage, and the crews’s ability to analyse its impact was clearly limited by their already high workload. As a result, they proceeded with the abandoned take-off plan while they considered how to deal with the new information.

Ten seconds before the aircraft stopped, the senior cabin crew member opened the flight deck door and said, “Say again?” The failure of the left engine had caused the aircraft’s PA system to use a lower setting, intended for before engine start. Many of the passengers had not heard the announcements over the PA system.

“Evacuate on the starboard side,” said the captain. It was now eight seconds before the aircraft came to a halt. The first officer was handling the aircraft however the nose-wheel steering was on the commanders side only. He was under an incredibly high workload, throughout keeping communications open with ATC and the cabin crew.

British Airtours Flight 28M as it turned from Runway 24 to Link D. Note right rear escape slide was already deployed.

As the aircraft was turning off the runway, the captain clearly began to register the situation. He brought the aircraft to a halt still partially on the runway, rather than continue with the turn.

Members of the fire service had heard a bang and saw the aircraft decelerating on runway 24. Black smoke and flames were already visible and the firemen had already initiated a response when the crash alarm siren sounded.

Once the engine had stopped, the captain told the first officer to carry out the engine fire drill on the left engine. He shut down the right engine.

The Senior Cabin Crew Member saw passengers standing up. He made an announcement asking them to please sit down and remain seated. He did not see any smoke or fire in the cabin.

Once the aircraft came to a halt, he went to the right front door to open it and release the inflatable escape slide. The door unlocked normally but then the lid of the slide container jammed on the door frame. He tried to clear the jam and then gave up and opened the left front door instead.

The forward spread of the fire was slow enough that he was able to open it fully and inflate the slide. It was 25 seconds after the aircraft had started.

The first fire vehicle was just arriving.

He left the evacuation with one of the cabin crew members. She apparently had to “pull free some passengers who had become jammed together”

The Rapid Intervention Vehicles discharged all their foam.

The first officer read the passenger evacuation drill from the Quick Reference Handbook. This was a non-memory drill and inexplicably long for the circumstance. “Passenger evacuation” was item fourteen in the list.

The captain saw fuel and fire spreading toward on the left side of the aircraft. He cut off the drill and ordered the first officer to evacuate the cockpit through the right-side sliding window on the flight deck.

The aft cabin suddenly filled with thick black smoke and the passengers panicked, pushing to get forward. Passengers stumbled and collapsed in the aisle, blocking the way.

Trapped passengers who couldn’t get into the aisles climbed over the seat-backs to get to the centre cabin area.

None of the passengers attempted to open the overwing exit. One reason for this may have been that in the flight safety card, it showed a person dressed as cabin crew opening the hatch, implying that a crew member should be the one to open the hatch.

The passengers in the first few rows were initially oblivious to the fire but those further back, especially row 14 and behind on the left side, could see the fire and soon the windows begin to crack and melt. That and the heat caused passengers to stand up in alarm. A male passenger shouted “Sit down, stay calm!” Similar calls were made by other passengers n the right hand side of the aircraft.

The dense, acrid smoke rapidly filled the cabin and many passengers reported that after one or two breaths, they could no longer breath or make any sound. The cabin became quiet except for the crackling of the flames. The heat was intense. The melting windows were acrylic, which starts to soften at 100° Celsius. One woman’s hair suddenly ignited.

The Senior Cabin Crew Member went back to the right-side door to clear the obstruction and began pushing the passengers down the chute. The smoke entered the galley area and swiftly became overwhelming. The crew member said that he couldn’t see across the galley and couldn’t see his slide. Visibility went down to inches and smoke was pouring out of the door. He believed that if he inhaled any more smoke, he would not survive. Another group of people came forward from the cabin. He got them onto the slide and then followed them down.

The cabin crew member at the left door faired no better. She found a young girl lying on the floor of the aisle and pushed someone back in order to pull the girl forward by the collar and push her down the slide. The smoke became too dense to see. She felt a body slump against her leg and found another female passenger. She dragged her by the waist and threw her onto the slide. The smoke forced her onto her hands and knees. She felt around for other passengers and, finding none, went down the slide where the fireman were waiting.

A passenger in the front row looked back and said that there was a mass of people tangled together in the centre section. They were howling and screaming but could not move forward. There was literally not enough space for the passengers to exit the aircraft.

Once the forward aisle was completely blocked, passengers attempted to open the overwing right exit. The woman seated in 10F was unable to get into the aisle. She saw the Emergency Pull instruction at the top of the hatch but pulled at the armrest, not knowing how the door was meant to open or where it was hinged. Her companion in the seat next to her stood up and reached across to pull the handle.

45 seconds had elapsed since the aircraft had come to a halt.

The hatch, which weighed 48 pounds, fell into the aircraft and landed across the chest of the passenger in 10F, trapping her in her seat. A man in Row 11 was able to drag the hatch off of her, which he threw onto seat 11D. The two women made it through the overwing exit, followed by other passengers from this area, including the other occupants of row 10 who were carrying an infant and a child in arms.

Dense black smoke filled the centre of the cabin and poured out of the overwing exit.

The rear doors were actually opened as the aircraft was still turning towards taxiway link Delta, six seconds before it came to a complete stop. External witnesses saw a cabin crew member visible in the doorway and the slide was deployed and inflated, but the doorway was obscured in thick black smoke. No passengers escaped through this door and neither of the cabin crew working the rear of the aircraft survived.

Four minutes after the aircraft had stopped, a British Airways crew coach arrived at the accident site to render first aid and comfort to the survivors and an injured fireman. They also led survivors away from the aircraft and onto coaches for transportation to a suitable holding area and then to the hospital.

The third delivery of foam arrived at the site. The fireman saw a hand move above what looked like a lifeless body hanging out of the right overwing exit. He left the vehicle and climbed onto the wing, where he was able to grab the hand of the now unconscious boy. He pulled him clear over the body of the man and handed him down to officers on the ground. The fireman was forced off the wing by smoke and was unable to get close to the door. He returned to his vehicle to apply foam to the top of the fuselage.

Aft section of the aircraft showing areas where fire burned through the hull and collapse of the tail section.

The unconscious boy was the last evacuee to survive the accident. It was 5½ minutes after the aircraft had stopped.

The aircraft had been stopped for seven minutes, less time than it probably took you to read to this point, when it because clear that no more passengers were going to make it out of the aircraft. Firemen wearing breathing apparatus boarded the still burning aircraft. An explosion blew one of the fireman out of the door. The officer in charge, who was concerned that the fire fighting vehicles were running out of water, ordered that no one else should attempt to enter the cabin until a water supply was ensured.

One of the firefighting crews (J1) travelled to the nearest hydrant to refill their water but discovered that the hydrant was dry. They tried three hydrants. None had any water. They returned to the scene, empty. The vehicle was dispatched to the hydrant behind the fire station, where they finally found water. However, the discharge rate was so slow, it took over 15 minutes to fill the tanks. By the time it returned to the scene, it was far too late.

It didn’t become clear until later why there was no water.

At the time of the accident, the water hydrant system on the airfield was in the process of being modified by the installation of an additional water main, which was being laid alongside the existing main south of the runway to provide increased flow rates. This work had been in progress for some considerable time prior to the date of the accident. To facilitate the interconnection of the new and original pipework it had been necessary from time to time to isolate sections of the system.

In the case of any work affecting the serviceability of the hydrants, it was established practice for the Senior Fire Officer to be informed in advance and the information promulgated on the fire station notice board

Investigation revealed that the system of work permits had not been adhered to; valves had been turned on and off by the contractor’s personnel without any form of control and without the knowledge of the fire service.

Greater Manchester Council Fire service arrived at the airport at the North rendezvous point, as per a decision made a month before the accident by the Head of Airport Services, the Airport Fire Officer and a Senior Fire Officer of Greater Manchester Council Fire.

However, the police were not invited of the meeting and hadn’t been told of the change of procedure. So they dispatched their escort vehicle to the original West rendezvous point in order to direct the external emergency services to the scene. A fire service ambulance also attempted to act as an escort vehicle but also went to the old meeting point. The Greater Manchester Council Fire service, carrying water desperately needed at the scene, waited at the North rendezvous point for three minutes before the escort vehicles could be redirected to collect them.

The divisional officer from the Greater Manchester Council took command of the emergency services. He did not know about the issues with the fire hydrants and ordered a relay set up to the closest hydrant, which now supplied water as expected. It turned out that contractors arriving for work had seen the fireman attempting to get water from the hydrants and silently restored the water supplies.

The divisional officer and another of the rescue services managed to board the aircraft but the conditions were still so poor, they could not continue. Two bodies were visible but there was no movement.

Thirty-three minutes after the aircraft had stopped, rescue workers discovered an unconscious man lying in the aisle near the front of the aircraft. They rescued him from the aircraft but he died six days later in hospital from the severe lung damage.

17 passengers escaped through the left front door.

34 passengers escaped through the right front door.

27 escaped through the overwing exit.

6 passengers died from direct thermal assault.

48 passengers died as a result of inhaling smoke and toxic gas.

Although the direct cause of the accident was clearly the failure of the left engine, the accident report focuses on the contributory causes.

The report cited the following major contributory factors:

  • the vulnerability of the wing tank access panels to impact
  • a lack of any effective provision for fighting major fires inside the aircraft cabin
  • vulnerability of the aircraft hull to external fire
  • extremely toxic nature of the emissions from the burning interior materials

The major cause of the fatalities was listed as rapid incapacitation due to inhalation of dense toxic/irritant smoke atmosphere within the cabin, aggravated by evacuation delays caused by a door malfunction and restricted access to the exits.

The report concludes:

Many of the factors which affected this accident should have biased events towards a favourable outcome. The cabin was literally intact, the aircraft remained mobile and controllable and no one had been injured during the abandoned take-off. The volume of fuel involved, although capable of producing an extremely serious fire, was relatively small compared with the volume typically carried at take-off, the accident occurred on a well-equipped major airport withe fire cover considerably in excess of that required for the size of aircraft and the fire service was in attendance within 30 seconds of the aircraft stopping. However, 55 lives were lost.

The full accident report is on the UK Aviation Accident Investigation Branch website.

This dreadful accident is considered definitive for modern crew training for dealing with fire and evacuations. All abandoned take-offs and emergency landings are now expected to end with a full stop on the runway to evaluate the situation. All flight crew are trained to consider the wind direction when bringing an aircraft to a halt in the case of an engine fire. A much simplified memory evacuation checklist has been adopted by all major airlines. A greater emphasis has been placed on ensuring that aircraft cabin materials are fire resistant and investments continue in developing onboard fire extinguishing systems. And finally, this accident is the reason why there is always extra space at the overwing exits and why passengers with children and infants are not allowed to sit at those exits.

Category: Accident Reports,

4 Comments

  • A terrible accident. With hindsight, a lot more people could have been saved but under the circumstances every crew member did his / her duty.

    Any comment would seem superfluous. Lessons have been learned; too late for those who perished in this accident but hopefully it will serve to save others.

  • It seems to me that there had been indications before this that cabins contained too much material that would throw off huge amounts of toxic smoke; see, for instance, Air Canada 797 (whose victims included folksinger Stan Rogers) over two years before. It’s unfortunate that information wasn’t acted on sooner (or more broadly?). It’s good to know that this event led to changes.

    • Funnily enough, I thought of Swissair Flight 111 just to discover it was ten years later. Air Canada 797 did the first real changes, to be fair: as a result smoke detectors and fire extinguishers were required on board, recommendations were made to teach passengers to open emergency doors and that more fire resistant material be used. It just wasn’t enough.

  • John Beardmore was among 131 passengers who boarded the ill-fated British Airtours flight 28M scheduled to leave for Corfu on 22 August 1985.

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