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Saudia Flight 163

Coordinates: 24°42′42″N 46°43′37″E / 24.71167°N 46.72694°E / 24.71167; 46.72694
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Saudia Flight 163
similar aircraft to that involved in the accident
Accident
Date19 August 1980
SummaryIn-flight fire in cargo hold
SiteRiyadh International Airport
Riyadh, Saudi Arabia
Aircraft
Aircraft typeLockheed L-1011-200 TriStar
OperatorSaudia
IATA flight No.SV123
ICAO flight No.SVA163
Call signSAUDIA 163
RegistrationHZ-AHK
Flight originQuaid-e-Azam Int'l Airport
Karachi, Pakistan
StopoverRiyadh International Airport
Riyadh, Saudi Arabia
DestinationJeddah International Airport
Jeddah, Saudi Arabia
Occupants301
Passengers287
Crew14
Fatalities301
Survivors0

Saudia Flight 163 was a scheduled Saudia passenger flight which caught fire after takeoff from Riyadh International Airport (now the Riyadh Air Base) en route to Jeddah, Saudi Arabia[1] on 19 August 1980. All 287 passengers and 14 crew on board the Lockheed L-1011-200 TriStar (registration HZ-AHK) died from smoke inhalation after the aircraft made a successful emergency landing at Riyadh.


Aircraft

The aircraft involved in the accident was a Lockheed L-1011 TriStar (flight registration HZ-AHK). It made its first flight on 13 July 1979, and was delivered to Saudia on 21 August 1979.[2]: 89 [3]

Crew

Nationalities of the victims [2][4]
Nationality Number
 Bangladesh 1
 Egypt 1
 Finland 1
 Iran 32
 Ireland 1
 Japan 1
 South Korea 1
 Netherlands 1
 Pakistan 85
 Philippines 6
 Saudi Arabia 154
 Sudan 1
 Thailand 2
 United Kingdom 4
 United States 3
Total 301

The captain of the flight was 38-year-old Mohammed Ali Khowyter, a Saudi who was hired by Saudia in 1965. He had flown numerous aircraft such as Douglas DC-3, DC-4, McDonnell Douglas DC-9, Boeing 707 and 737. However, Khowyter was not a gifted pilot as his records described him as a slow learner and needing more proper training. Khowyter had 7,674 flying hours, including 388 hours in the TriStar. The first officer was 26-year-old Sami Abdullah M. Hasanain, who joined the airline in 1977 and had previously worked as a trainee. He received his type rating on the TriStar eleven days before the accident. However at one point during his training, due to his poor performance, Hasanain was removed from flying school. Hasanain had 1,615 flying hours, including 125 hours in the TriStar. The flight engineer was 42-year-old Bradley Curtis, an American who was hired by the airline in 1974. He had been qualified as a captain of the Douglas DC-3, and was then assigned to train in either the Boeing 707 or 737, but failed to qualify as both a captain and as a first officer because he did not meet the requirements. He had needed to pay for his own training as an L-1011 flight engineer in order to keep his job. Curtis had 650 flying hours, including 157 hours in the TriStar.[2]: 86–88 [5]

Passengers

Eighty-two of the passengers boarded in Karachi while the remaining 205 passengers who boarded in Riyadh. The majority of the passengers were Saudis and Pakistani religious pilgrims on their way to Mecca for a traditional Ramadan holiday. In addition to the Saudis and Pakistanis, there were 32 religious pilgrims from Iran. There were also small number of passengers from various countries, who were heading to Jeddah for diplomatic missions.[2]: 89 [6][7]

Accident

The burnt-out aircraft after the fire was extinguished.
An overview of Saudia Flight 163 after the fire.

Flight 163 departed Qu'aid-e-Azam International Airport (now Jinnah International Airport) in Karachi, Pakistan at 18:32 Pakistan time (13:32 UTC) bound for Jeddah International Airport in Jeddah, Saudi Arabia, with a scheduled intermediate stop at Riyadh Airport. The flight arrived in Riyadh at 19:06 Saudi time (16:06 UTC). There was a two hour layover for refueling/ During the layover several of the passengers disembarked. After refueling, the flight took off at 21:08 (18:08 UTC) bound for Jeddah. Almost seven minutes into the flight the crew received warnings of smoke from the cargo compartment.[2]: 66–67, 98  The next four minutes were spent by the crew trying to confirm the warnings, flight engineer Curtis went back into the cabin to confirm the presence of smoke. Captain Khowyter decided to return to the airport. At 21:25 (18:25 UTC), The thrust lever for the number two engine (the center engine) became jammed as the fire burned through the operating cable. Then, at 21:29 (18:29 UTC), the number two engine was shut down during final approach.

At 21:35 (18:35 UTC), Khowyter declared an emergency and landed back at Riyadh.[8] After touchdown at 21:39 (18:39 UTC), the airplane continued to a taxiway at the end of the runway and exited the runway[where?], stopping on the taxiway two minutes 40 seconds after touchdown. The airport fire rescue equipment was stationed at the landing section of the runway, with emergency personnel expecting an emergency stop and evacuation. Why Khowyter did not immediately order an emergency evacuation of the aircraft is unknown. Because the fire rescue equipment was farther down the runway it took extra time to arrive at the aircraft, which had used the entire length of a 13,000 feet (4,000 m) runway to slow and then exit onto the taxiway, where it stopped facing in the opposite direction from landing.[clarification needed]

On arrival at the aircraft at 22:05 (19:05 UTC), the rescue personnel did not immediately attempt to open any of the aircraft doors as the two wing-mounted engines were still running. These were shut down three minutes and 15 seconds after the aircraft came to a stop. No external fire was visible at this time, but flames were observed through the windows at the rear of the aircraft. Twenty-three minutes after engine shutdown, the R2 door (second door on the right side) was opened by ground personnel. Three minutes later, the aircraft burst into flames, and was consumed by fire.[2]: 8  At 22:09 (19:09 UTC), all of the victims were found in the forward half of the fuselage. The crew were found still in their flight-station seats. One final transmission was received after the plane stopped, indicating that the emergency evacuation was about to begin.

Investigation

Cargo compartment C3 after the fire.

The investigation revealed the fire had started in the aft C3 cargo compartment.[2]: 77–78  The fire was intense enough to burn through the cabin floor, causing passengers seated in that area of the cabin to move forward prior to the landing. Saudi officials found two butane stoves in the burned-out remains of the airliner, and a used fire extinguisher near one of them.[2]: 35  One early theory was that the fire began in the passenger cabin when a passenger used his own butane stove to heat water for tea.[9] The investigation found no evidence to support this theory.[2]: 78 

Investigation

Saudi Arabia appointed the US Airline Consultant as the Head of Investigation. The investigation was assisted by US NTSB, UK AAIB, Lockheed and Trans World Airlines.[2]: 81  The accident investigation focused on four areas: fire ignition, crew operations, rescue personnel and survival opportunities.[2]: 63 

Source of ignition

The point where the fire burned C-3 cavity burst.

The investigation revealed the fire had started in the aft C3 cargo compartment.[10]: 77–78  The fire was intense enough to burn through the cabin floor, causing passengers seated in that area of the cabin to move forward prior to the landing. Saudi officials found two butane stoves in the burned-out remains of the airliner, and a used fire extinguisher near one of them.[2]: 35  One early theory was that the fire began in the passenger cabin when a passenger used his own butane stove to heat water for tea.[11][12] The investigation found no evidence to support this theory.[2]: 78 

Crew resource management

The operation of the crew to ensure fire was normal and in accordance with Saudia's instructions. It took three minutes to find the right checklist. This was due to the fact that in the Saudi manuals the emergency measures were divided into three sections: action in emergencies, action in exceptional circumstances and others. The crew searched for the fire alarm checklist first in the emergency situation, even if it was in an emergency. Some of the activities were also delayed by the flight engineer's dyslexia.[2]: 70 

After the plane turned to Riyadh, the crew was weak. The captain focused entirely on flying the aircraft even though he could have given the lead to the co-pilot and focus on assessing the situation itself. In addition, the operations of the airline engineer might confuse the captain. She repeatedly "did not worry, did not worry," even though the situation was serious. This may have been partly due to the fact that the captain did not respond to the situation with the seriousness it requires. Nevertheless, the captain received several signs of burning in the machine. He should have instructed the cabin crew to prepare for evacuation immediately after landing and command both cabin and flight crew to use oxygen doctors if necessary. The co-worker did not bring himself up or offered his help to the captain.[2]: 70  The cabin staff, on the other hand, acted exemplarily during this time. They tried to shut down the fire, did their best to calm the passengers, tried to get the captain to understand the severity of the situation and asked repeatedly whether the machine should evacuate. After landing, the captain should have stopped the machine as soon as possible and start evacuating immediately. Instead, he rolled to the runway and turned away from the runway. Immediate halting time would have spared about two minutes.[2]: 71 

Saudi reports stated that the crew could not get the plug-type doors to open in time.[13] It is assumed that most passengers and flight attendants were incapacitated during the landing roll, or they would not have attempted to open a door on a moving aircraft.[14] It is known that the aircraft remained pressurized during the landing roll as the cabin pressurization system was on standby, and the aircraft was found with both pressurization hatches almost completely closed. The pressurization hatches should have opened completely on touchdown to depressurize the aircraft. Just before the landing, the captain said in the cockpit that the aircraft was not evacuated, but it is not certain whether the command was forwarded. Saudi cabin staff were entitled to decide on evacuation if necessary, but the captain prevented this from keeping the engines running. The opening of the doors could also prevent the panicked passengers, who were pushing the doors to the doors as they pressed their doors, so that they could not be moved by a few cents inward. According to the researchers, however, it is more likely that the fire resulted in loss of crew performance after engine shutdown, but before the evacuation began. An evacuation command is unlikely to even be given.[2]: 72 

Rescue work

Riyadh airport rescue staff were inadequate and inorganic. They did not have the right kind of protective equipment or tools. They had not been trained to open the L-1011's doors or even shut down the fires. Firefighters should have opened the doors immediately after the machine stops. In the beginning, their delay was explained by the fact that engine motors were still running and they had no direct contact with the crew. However, the Panel noted that 26 minutes is too long to stop the machine from opening the doors.[2]: 74 

Survival aspects

Autopsies were conducted on some of the non-Saudi nationals, including the American flight engineer. All of them perished from smoke inhalation and not burns, which indicated that they had died long before the R2 door was opened.[2]: 75 

From the discovery of smoke during the landing season, passengers were exposed to a mild, virtually insignificant oxygen deficiency and an increasing amount of carbon monoxide and other combustion gases. However, the exposure was not large enough to affect the passenger's ability to function. After settling, the conditions deteriorated rapidly. The captain's delay at this stage led to a rapid escalation of the danger posed to the aircraft. The investigation would have made it possible for people to survive. The captain's delay, the failure to evacuate the mandate and the ineffective operation of the rescue staff led to no one surviving.[2]: 75 

Aftermath

Policy changes

After the event, the airline revised its training and emergency procedures. Lockheed also removed the insulation from above the rear cargo area, and added glass laminate structural reinforcement. The National Transportation Safety Board recommended that aircraft use halomethane extinguishers instead of traditional hand-held fire extinguishers.[15]

Flight 163 encapsulated the further need for an advent of crew resource management. This is evident from the primary lapses in effective communication which prevented the crew from carrying out a final successful evacuation from the aircraft. These lapses are enabled in part by so-called "power distances" between juniors and superiors in workplace settings, relationships found in all societies but emphasized more so in some than in others.[16] "In high power distance cultures, juniors do not question superiors and leaders may be autocratic", leading to situations where a first officer finds it difficult to question decisions made by the captain, conditions which may have been present on Saudia flight 163.[17][16][18] This phenomenon has the capability of affecting flight safety globally, but as the work performed in the cockpit is markedly dependent upon the ability of one worker to crosscheck the work of another and vice versa, the danger is most apparent in individuals brought up in cultures which traditionally revere high-power distances between those in positions of power and their subordinates.[17] In 1982, the British current-affairs program World in Action aired an episode entitled "The Mystery of Flight 163". This documented the accident, and was subsequently used to train pilots in the value of crew resource management.[19]

Lawsuit

Walter Muller, a former chief of the Policy Analysis Division of the Federal Aviation Administration, filed a lawsuit against Lockheed, Saudia, and Trans World Airlines, an American airline that trained Saudi pilots and supervised the Saudi maintenance program. Muller's brother, Jack A. Muller, and his sister in law, Elizabeth S. Muller, died in the fire. Muller's suit stated that Lockheed allowed for "dangerous materials to be incorporated in the fuselage," that there was no vent system to distribute the gases away from the passengers, and that a sufficient oxygen system did not exist. Muller's suit accused Saudia of not properly maintaining the aircraft and providing safety for passengers, and accused TWA of not properly maintaining the Saudia aircraft and not properly training crew.[20][21][22] The suit was dismissed by the Federal Court in the Washington DC on 20 May 1982.[23]

See also

References

  1. ^ "ASN Aircraft accident Lockheed L-1011 Tristar 200 HZ-AHK Riyad International Airport (RUH)".
  2. ^ a b c d e f g h i j k l m n o p q r s t "Aircraft Accident Report, Saudi Arabian Airlines Lockheed L-1011, HZ-AHK, Riyadh, Saudi Arabia August 19th, 1980" (PDF). Federal Aviation Administration. Saudi Arabian Presidency of Civil Aviation. Archived from the original (PDF) on 31 December 2013. Retrieved 26 February 2017. {{cite web}}: Unknown parameter |dead-url= ignored (|url-status= suggested) (help)
  3. ^ "Saudia HZ-AHK (Lockheed L-1011 TriStar - MSN 1169)". Airfleets aviation. Retrieved 28 February 2018.
  4. ^ Template:Https://www.washingtonpost.com/archive/politics/1980/08/21/saudi-plane-deaths-total-301/850d42a9-3844-4e15-8442-489bf2ddd2d7/?noredirect=on&utm term=.78aa555c2500
  5. ^ Thomson, Jim (16 January 1982). "Human behaviour in a crisis - Saudia 163" (PDF). Retrieved 2 March 2018.
  6. ^ "Mecca pilgrims among victims Gas stoves found in burned plane". The Globe and Mail. 29 August 1980.
  7. ^ Haine, Edgar A. (2000). Disaster in the Air. Associated University Presses. pp. 67–69.
  8. ^ "265 Are Feared Dead As Saudi Plane Burns In Landing at Riyadh". The New York Times. UPI. 20 August 1980. Retrieved 26 February 2017.
  9. ^ "Jetliner fire first started by stove; death toll set at 301". The Morning Record and Journal. United Press International. 21 August 1980. p. 22.
  10. ^ "Aircraft Accident Report, Saudi Arabian Airlines Lockheed L-1011, HZ-AHK, Riyadh, Saudi Arabia August 19th, 1980" (PDF). Federal Aviation Administration. Saudi Arabian Presidency of Civil Aviation. Archived from the original (PDF) on 31 December 2013. Retrieved 26 February 2017. {{cite web}}: Unknown parameter |dead-url= ignored (|url-status= suggested) (help)
  11. ^ "Smuggled gas stove may have caused Saudi plane disaster" (303). 21 April 1980: 9A. {{cite journal}}: Cite journal requires |journal= (help)
  12. ^ "Jetliner fire first started by stove; death toll set at 301". The Morning Record and Journal. United Press International. 21 August 1980. p. 22.
  13. ^ "Saudi Fire Negligence Suit Filed". Air Transport. Aviation Week & Space Technology. 27 October 1980. p. 32.
  14. ^ Witkin, Richard (21 August 1980). "Fire on Saudi Plane Believed to Have Started in Cabin: Cockpit Escape Hatch Not Used". The New York Times. NYTimes Co. Retrieved 26 February 2017.
  15. ^ Haine, Edgar A. (2000). Disaster in the Air. Associated University Presses. pp. 67–69.
  16. ^ a b Helmreich, Robert L.; Davies, Jan (2004). "Culture, Threat, and Error: Lessons from Aviation" (PDF). Canadian Journal of Anesthesia. 51 (6): R2. doi:10.1007/bf03018331.
  17. ^ a b Trkovsky, Josef (2017). Improved Flight Safety Through Effective Communication Among Multicultural Flight Crew (Ph.D. thesis). Scottsdale, Arizona: Northcentral University. pp. 4, 6–7, 104–114. Dissertation No.10278679 – via ProQuest Dissertations Publishing.
  18. ^ Helmreich, RL; Klinect, JR; Wilhelm, JA; Merritt, AC (2001). "Culture, Error, and Crew Resource Management". In Salas, Eduardo; Bowers, Clint A; Edens, Eleana (eds.). Improving Teamwork in Organizations: Applications of Resource Management Training. Lawrence Erlbaum Associates. ISBN 0805828443.
  19. ^ Karlins, Marvin; Koh, Freddie; McCully, Len; Chan, C. T. "CRM for CRM: Cockpit Relevant Movies for Crew Resource Management". The CRM Advocate.
  20. ^ Haine, Edgar A. (2000). Disaster in the Air. Associated University Presses. pp. 67–69. ISBN 0-8453-4777-2.
  21. ^ "Saudi Fire Negligence Suit Filed". Air Transport. Aviation Week & Space Technology. 27 October 1980. p. 32.
  22. ^ Witkin, Richard (17 October 1980). "Family Suing in Saudi Airliner Fire; Crew Found Partly at Fault". The New York Times.
  23. ^ "In Re Disaster at Riyadh Airport Saudi Arabia, Etc., 540 F. Supp. 1141 (D.D.C. 1982)". Justia. U.S. District Court for the District of Columbia. 20 May 1982. Retrieved 3 August 2016. {{cite web}}: Cite has empty unknown parameter: |dead-url= (help)
External image
image icon Airliners.Net Picture of Saudia 163

24°42′42″N 46°43′37″E / 24.71167°N 46.72694°E / 24.71167; 46.72694

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