1985 Manchester Airport disaster

British Airtours Flight 28M

A similar British Airtours Boeing 737–236 Advanced, named River Wey, wearing British Airtours' Landor Associates livery at the time of the accident.
Accident
Date	22 August 1985, 06:12 BST
Summary	Fire on the ground caused by uncontained engine failure
Site	Manchester Airport Manchester, England 53°20′45″N 2°17′36″W
Aircraft
Aircraft type	Boeing 737–236 Advanced
Aircraft name	River Orrin (formerly Goldfinch)
Operator	British Airtours
Registration	G-BGJL
Flight origin	Manchester Airport
Destination	Corfu International Airport
Passengers	131
Crew	6
Fatalities	55 (54 on site, 1 subsequently in hospital (53 passengers, 2 crew))
Injuries	15 (serious)
Survivors	82

British Airtours Flight 28M was an international passenger flight, originating from Manchester International Airport's Runway 24 in Manchester, England, en route to Corfu International Airport on the Greek island of Corfu. On 22 August 1985, the route was being fulfilled by Boeing 737–236 G-BGJL, when take-off from Manchester Airport was aborted due to engine failure.

The aircraft, previously named "Goldfinch", but at the time of the accident named "River Orrin", had 131 passengers and six crew on the manifest. At 06:12 BST during the takeoff roll, a loud thump was heard. An engine failure had generated a fire and a plume of black smoke ensued. Takeoff was aborted and the captain ordered the evacuation of the aircraft, with 78 of the 131 passengers escaping. 53 passengers perished along with two members of the cabin crew. Most of the deaths were due to smoke inhalation.

The accident was instrumental in bringing about changes to make aircraft evacuation more effective. Acting on the recommendations of the UK's Air Accidents Investigation Branch (AAIB), which investigated the accident, the aviation industry introduced changes to the seating layout near emergency exits, fire-resistant seat covers, floor lighting, fire-resistant wall and ceiling panels, more fire extinguishers and clearer evacuation rules.

Accident

Attempted takeoff

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

The flight crew consisted of Captain Peter Terrington (39) and First Officer Brian Love (52), both seasoned pilots with 8,441 flight hours and 12,277 flight hours, respectively. At 06:12 BST, during the takeoff phase, the pilots heard a loud thump coming from underneath the plane. Thinking a tyre had burst, the captain ordered an abandoned takeoff and then activated the thrust reversers. The first officer, who was in control of the aircraft at the time, applied "harsh" braking for approximately five seconds. The captain, concerned about a burst tyre, instructed the first officer to use less wheel braking, which was done. Fire warnings sounded in the cockpit nine seconds after the thump was heard (about 36 seconds before the aircraft stopped). Ten seconds later, the tower controller confirmed, "right, there's a lot of fire." Twenty-five seconds after the thud was heard (about 20 seconds before the aircraft stopped), the tower controller suggested evacuating passengers to the starboard side. The tower controller activated the airport's fire alarm siren the moment he first saw smoke coming from the aircraft, but firefighters working for the airport's fire service had heard a "bang" and seen the smoke and fire for themselves, and had already initiated a response on their own.

Forward evacuation

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

The aircraft turned off the runway onto a short taxiway called link "D" and came to a full stop facing northwest. Evacuation efforts began immediately, but several difficulties were encountered. The purser tried to open the right front exit door about ten seconds before the aircraft stopped, but it would not open more than a "crack" due to a design fault in the emergency slide system. After about 25 seconds, the purser opened the left front door and successfully deployed the escape slide. At this time, the first two fire service appliances (i. e., fire trucks) arrived, and one began showering the fuselage and the open door with foam to prevent the fire from spreading to the door and the slide as passengers were evacuating, and to provide cooling to protect the passengers still inside. When the second appliance arrived, the first concentrated on the burning fuel and the left engine. The second appliance sprayed foam over the fuselage and the open door. During this time, the "No 4 stewardess" had kept passengers out of the forward galley area to allow the purser time to open a door. When the left side door was opened, a jam had developed in the narrow (22.5 inch-wide) passageway between the two forward galley bulkheads. The No 4 stewardess physically pulled the passengers out one at a time until the jam was relieved. Meanwhile, the purser had resumed working on the right front door, and he successfully opened the door fully and deployed the escape slide about one minute after the plane had stopped. Sixteen passengers and the No 4 stewardess escaped through the left front door, one of whom was unconscious and the No 4 stewardess dragged her out physically. The purser and 34 passengers made their escape through the right front door.

Overwing evacuation

Photograph showing seats relative to the right overwing emergency exit after the accident. Note the position of the arm rest. The seat back for the seat closest to the window, seat 10F, was returned to its upright position before this photo was taken.

More difficulties were encountered at the overwing exits. The left overwing exit could not be used because it was blocked by smoke and flames. The passenger seated at the right overwing exit had difficulty understanding how to operate the hatch. At that time, there was no requirement that exit-row passengers receive a briefing on how and when to open the hatch. Once the 48 lb hatch was released, it fell inward onto the passenger seated next to it, trapping her. Two passengers lifted the hatch and put it on a seat in the next row back, making the exit available for use 45 seconds after the aircraft had stopped. Once the hatch had been removed, passengers still encountered difficulties in getting to and using this exit. The exit row seats allowed only 10.5 inches of space to pass through, the armrests between those seats remained down, and the exit was situated directly over a seat, requiring passengers to manoeuvre awkwardly to make their escape. Passengers in the rear of the aircraft were panicking as smoke, and eventually flames, filled the hot cabin at about the same time the right overwing exit was opened. Passengers crawled over seat backs to get to the right overwing exit as well as the two front exits; some survivors told investigators that the aisle had become blocked with bodies. Not only did this cause jamming at all exits, the seat over which the overwing exit was located failed in such a way that the seat back collapsed forward, providing a further obstruction. A man who had been seated in 16C was found dead lying across this exit, and investigators were unsure whether the seat back collapse had trapped the man, preventing his escape. A fourteen-year-old boy was found lying across the top of the man from seat 16C by firefighters 5.5 minutes after the aircraft had stopped. He was alive, suffering only superficial burns to his hands. He was the last of 27 survivors to escape through that exit, and the last evacuee to survive the accident. Most of the bodies (38) were found clustered around the overwing exit. This exit was the first exit available to the 76 passengers seated behind it or even with it, and the nearest exit for 100 passengers.

Fire and loss of aft exits

Orientation of wind, pooling fuel, and flames relative to the aircraft after it stopped on taxiway link D.

Aft section of the aircraft showing areas where fire burned through the hull and collapse of the tail section. Note that the left rear door and the left overwing exit were both opened by firefighters after rescue operations were complete.

Fuel had been spilling from the port wing from the moment the first loud noise was heard. That fuel had ignited on contact with flames emanating from the hole in the engine combustion chamber as the aircraft began to decelerate on the runway. When the aircraft came to a stop, fuel was still leaking from a 42 in² opening at a rate of 2 - 3 US gallons per second, feeding a growing fire. By about this time, the fire had already penetrated the aluminum alloy skin of the aircraft below the level of the floor in the passenger compartment. (The AAIB estimated that it took between five seconds before and thirteen seconds after the aircraft stopped for fire to penetrate the fuselage skin.) Passengers seated on the left side of the aisle and toward the rear felt intense radiant heat from the fire, and were very impatient to escape, many of them standing and moving into the aisles while the aircraft was moving.

As the aircraft began its right turn off the runway, approximately 10 seconds before it stopped, one of the two flight attendants in the rear of the aircraft, probably the No 3 stewardess, opened the right rear door and deployed the emergency chute. When the aircraft came to a stop, this exit was unusable. The aircraft was facing the northwest, and a light wind of 6 - 7 knots was blowing from the west. The wind was enough to carry dense smoke, and occasionally flames, in through that door. When the door was first opened, the aircraft had been facing into the wind, and the exit had been clear. (One aviation expert said in a 2010 interview with the BBC that if such an incident were to happen then, the new procedure would be to leave the aircraft on the runway and evacuate it in place, even if it meant closing the airport as a result.) No one escaped through this door. However, when the left front door was opened, this created an airflow from the front of the aircraft to the rear, and out through the right rear door, which likely contained the smoke to the rear of the aircraft. When the right overwing exit and the right front exit were opened, this flow was lost, and the entire cabin rapidly filled with smoke. The left rear exit remained closed.

Fire penetrated into the rear portion of the passenger cabin through the floor and along the left wall within one minute of the aircraft coming to a stop. The investigators working on this accident commented that this quick penetration of fire into the cabin appeared "to conflict markedly with the air transport industry's expectations" for this type of fire, which at that time expected one to three minutes would be available for evacuation before the fire would be "in a position to directly threaten the occupants".

When firefighters determined that no more passengers would leave the aircraft unassisted, they entered the passenger cabin with fire hoses and attempted to extinguish the blaze inside the aircraft. By this time, efforts to fight the fire inside the aircraft were futile and unsafe. One firefighter was slightly injured when an explosion threw him out the door and down to the tarmac. The cause of the explosion was not determined, but heat-induced overpressure and rupture of an aerosol spray can or therapeutic oxygen cylinder are suspected.

Casualties

Toxic smoke and fire caused the deaths of 53 passengers and two cabin crew, 48 of them from smoke inhalation. 78 passengers and four crew escaped, with 15 people sustaining serious injuries. One passenger, a man rescued 33 minutes after the outbreak of fire, was found unconscious in the aisle, but died in the hospital 6 days later as a result of injuries to his lungs and the resulting pneumonia.

Colours represent the exit taken by survivors. Red crosses show fatalities.

Causes

The AAIB report lists a cause for the accident and a separate cause for the fatalities, as well as four contributing factors.

Accident

The subsequent investigation into the incident revealed that the No. 9 combustor can on the port engine ruptured, and a section of the can was ejected forcibly into an underwing fuel tank access panel. That panel was fractured, allowing fuel to spill onto hot combustion gases from the engine. The resulting fire developed catastrophically, primarily due to the orientation of the aircraft and the fire to the wind, "even though the wind was light."

Fatalities

The AAIB concluded that "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 forward right door malfunction and restricted access to the exits."

Contributing factors

The AAIB listed the following as major contributory factors:

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

Previous engine repair

Records showed the engine in question, a Pratt & Whitney JT8D-15, had experienced previous cracks to the No. 9 combustor can that had been repaired in 1983 by fusion welding. However, the repair did not include solution heat treatment, which was a required procedure for this type of repair. The AAIB evaluated conflicting evidence on the effect of solution heat treatment and "considered that it would not have had a significant effect on the fatigue life of the can." The circumferential edges of the severed forward section of the No. 9 can coincided with some of the cracks that had been welded during that repair. However, some of the fracture occurred in areas where there had been no cracking observed at the time of the repair, and the fracture edges were severely damaged during the failure and the ensuing fire. Therefore, the Air Accidents Investigation Branch could not conclude whether the quality of the repair had caused or contributed to the accident.

Aftermath

The incident raised serious air safety concerns relating to survivability, something that prior to 1985 had not been studied in such detail. The Civil Aviation Authority was criticised by some for not implementing stringent safety regulations earlier.

The swift incursion of the fire into the fuselage and the layout of the aircraft impaired passengers' ability to evacuate, with areas such as the forward galley area becoming a particular bottleneck for escaping passengers. Of those unable to escape, 48 died as a result of incapacitation and subsequently lethal toxic gas and smoke inhalation, some very close to the exits, with six dying from burns.

A large amount of dynamic research into evacuation and cabin and seating layouts was undertaken at Cranfield Institute to try to measure what makes a good evacuation route. This work led to the seat layout adjacent to overwing exits being changed by mandate, and the examination of evacuation requirements relating to the design of galley areas.

The use of smoke hoods or misting systems was also examined although both options were rejected.

Awards

The surviving cabin crew - Arthur Bradbury and Joanna Toff - and two members of the Manchester Airport Fire Service - Fireman Samuel Lyttle and Fireman Eric Arthur Westwood - were all awarded the Queen's Gallantry Medal, and the two flight attendants who died - Sharon Ford and Jacqui Urbanski - received the same award posthumously. Their collective citation stated in summary:

"Mr. Bradbury, Miss Ford, Miss Toff, and Mrs. Urbanski displayed coolness, outstanding courage and devotion to duty. They remained at their posts and saved many lives. Firemen Lyttle and Westwood also displayed outstanding bravery and disregard for their own safety when they mounted the wing to rescue passengers."

See also

Similar events

• British Airways Flight 2276
• Air Canada Flight 797
• China Airlines Flight 120
• Swissair Flight 111
• Nigeria Airways Flight 2120
• South African Airways Flight 295
• TWA Flight 800
• Saudia Flight 163
• Air France Flight 358

References

Citations

Bibliography

• Faith, Nicholas (1998). Black Box:The Final Investigations. United Kingdom: Boxtree. pp. 80–90. ISBN 0-7522-2118-3.

External links

External image
Photos of G-BGJL in its older color scheme and named Goldfinch (Airliners.net)

• Report No: 8/1988. Report on the accident to Boeing 737–236, G-BGJL, at Manchester Airport on 22 August 1985 (Air Accident Investigation Branch).
• Parry, Gareth, Tom Sharratt, and Harold Jackson. 54 killed as Boeing bursts into flames, Guardian. Friday 23 August 1985. – news report at the time of the accident.