Crash-aerien 22 AUG 1985 d'un Boeing 737-236 G-BGJL - Manchester International Airport (MAN)

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Statuts:	Accident investigation report completed and information captured
Date:	jeudi 22 ao�t 1985
Heure:	07:13
Type/Sous-type:	Boeing 737-236
Compagnie:	British Airtours
Immatriculation:	G-BGJL
Numéro de série:	22033/743
Année de Fabrication:	1981-02-26 (4 years 6 months)
Heures de vol:	12977
Cycles:	5907
Moteurs:	2 Pratt & Whitney JT8D-15A
Equipage:	victimes: 2 / à bord: 6
Passagers:	victimes: 53 / à bord: 131
Total:	victimes: 55 / à bord: 137
Dégats de l'appareil:	Détruit
Conséquences:	Written off (damaged beyond repair)
Lieu de l'accident:	Manchester International Airport (MAN) ( Royaume Uni)
Élévation des lieux de l'accident:	78 m (256 feet) amsl
Phase de vol:	Au décollage (TOF)
Nature:	Charter International
Aéroport de départ:	Manchester International Airport (MAN/EGCC), Royaume Uni
Aéroport de destination:	Kerkyra-I. Kapodistrias Airport (CFU/LGKR), Grèce
Numéro de vol:	KT328

Détails:
British Airtours Flight 328 (also known as flight 28M) was a charter flight from Manchester to Corfu. At 06:08 in the morning the crew were cleared to taxi to runway 24 for departure. At 06:12 the aircraft had lined up on the runway and was cleared for takeoff. The takeoff was to be performed by the co-pilot. During the takeoff run the captain made the routine 'eighty knots' call and 12 seconds later a 'thump' or 'thud' was heard. The captain immediately ordered 'stop', closed the throttles an selected reverse thrust. The maximum speed achieved was 126 knots IAS. At first the captain thought they had suffered a tyre burst or a bird strike. The co-pilot had applied maximum wheel braking, however, because of the possible tyre burst, the captain said 'Don't hammer the brakes, don't hammer the brakes'. At 45 seconds after the start of the takeoff run, 9 seconds after the 'thud', as the aircraft decelerated trough 85 knots the captain radioed ATC that they were abandoning takeoff. The fire bell rang simultaneously and he added as he cancelled reverse thrust, 'it looks as though we've got a fire on number 1'. ATC confirmed this: 'right there's a lot of fire, they're on their way now.'. At 25 seconds past the 'thud' (and 20 seconds before the aircraft stopped) the crew decided to evacuate via the starboard side. The 737 was decelerating through 36 knots then and the captain warned the cabin crew about the evacuation six seconds later. After the aircraft stopped a no. 1 engine fire drill was carried out, the no. 2 engine was shut down and the passenger evacuation drill carried out. Before completion of this drill the captain saw fuel and fire spreading forward on the left side of the aircraft. Both flight crew members escaped through the sliding window in the right hand side.
Immediately after the 'thud' an intense fire developed on the left-hand side of the plane, causing some cracking and melting of windows with some associated smoke in the aft cabin. This caused some passengers to stand up in alarm and move into the aisle. Immediately after coming to a halt the purser tried to open the right front door (R1) but the escape slide container jammed on the doorframe, preventing further movement of the door. He then crossed to the L1 door and opened it (25 seconds had passed since the aircraft had stopped). The purser then returned to the R1 door and managed to clear the obstruction and was able to open the door 85 seconds after the aircraft had stopped. Meanwhile passengers had managed to open the right hand overwing exit. The R2 (right rear) door had also been opened but no one escaped through this exit. In total 17 surviving passengers escaped through the L1 door, 34 through R1 and 27 through the overwing exit.

Probable Cause:

PROBABLE CAUSE: "The cause of the accident was an uncontained failure of the left engine, initiated 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 wing tank 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 forward right door malfunction and restricted access to the exits. "

Accident investigation:

Investigating agency:	AIB
Status:	Investigation completed
Duration:	3 years and 4 months
Accident number:	AAR 8/88
Download report:	Final report

Sources:

» SKYbrary

Opérations de secours

AAIB issued 31 Safety Recommendations
FAA issued 1

Issued: 25-AUG-1985	To: JT8D-15	T85-17-51
Immediate inspection for evidence of combustion chamber distress (and repair or replacement, if necessary) of all JT8D-15 engines with certain combustion chambers (Part Nos. 778714 and 778715), except for those engines maintained under an ECM program approved by the FAA.
Issued: 19-SEP-1985	To: CAA	G-BGJL (10)
A review of the approval of the cabin configuration as it existed on G-BGJL should be conducted, with particular reference to the following features of that configuration: i) The restricted view of the passenger cabin afforded the forward cabin crew when seated.; ii) The forward aisle restriction created by the floor to ceiling forward galleys.; iii) Access to the overwing exit where the presence of row 10 seats appeared to conflict with the British Civil Airworthiness Requirements. It is recommended that all row 10 seats be removed. The approval of other configurations on Boeing 737 and other types should also be reviewed with the intention of addressing any similar problems.
Issued: 19-SEP-1985	To: CAA	G-BGJL (5)
Emergency equipment for use by cabin crew during an emergency evacuation should be stowed at the cabin crew stations.
Issued: 04-DEC-1985	To: CAA	G-BGJL (12)
A requirement should be introduced for passenger public address systems that can continue to function largely independently of engine or airframe system condition, and provide a high gain mode for use in emergencies.
Issued: 04-DEC-1985	To: CAA	G-BGJL (24)
The Civil Aviation Authority should urgently give consideration to the formulation of a requirement for the provision of smokehoods/masks to afford passengers an effective level of protection during fires which produce a toxic environment within the aircraft cabin.
Issued: 14-MAR-1986	To: CAA	G-BGJL (1)
Procedures should be developed to enable the crew to position an aircraft, when a ground fire emergency exists, with the fire downwind of the fuselage. Visual indicators of local wind direction located within the manoeuvre areas would be valuable aids to the implementation of such a procedure.
Issued: 15-DEC-1988	To:	G-BGJL (11)
A review should be conducted to examine the adequacy of existing British Civil Airworthiness Requirements relating to \'unobstructed access\' to exits and these updated where necessary to take account of modern high density seating configurations.
Issued: 15-DEC-1988	To:	G-BGJL (13)
Operators should adopt a policy of distributing the most experienced cabin crew throughout the passenger cabin.
Issued: 15-DEC-1988	To:	G-BGJL (14)
A requirement should be introduced for an effective communication system for Rescue and Fire Fighting personnel as part of the licensing requirements for all major airports. That requirement should include provision for communication on the same system by the officer in charge of the units deployed by any local authority fire service having standing arrangements to attend such airports.
Issued: 15-DEC-1988	To:	G-BGJL (15)
The recruitment and training of airport fire officers should be amended to facilitate a more management orientated approach.
Issued: 15-DEC-1988	To:	G-BGJL (16)
RFF personnel in breathing apparatus should be positioned by overwing and other exits at the earliest opportunity to assist those evacuating and to help keep the exits clear. This would require the airport fire service to be equipped with additional breathing apparatus and all RFF personnel to be trained in its use.
Issued: 15-DEC-1988	To:	G-BGJL (17)
A requirement should be introduced for some form of standardised high visibility clothing to be worn by the officer in charge of the Rescue and Fire Fighting personnel at any incident/accident scene.
Issued: 15-DEC-1988	To:	G-BGJL (18)
A thorough review should be undertaken into techniques for extinguishing fires inside the passenger cabins of public transport aircraft, with a view to rectifying the current deficiencies in airfield firefighting capability when dealing with internal fires.
Issued: 15-DEC-1988	To:	G-BGJL (19)
Onboard water spray/mist fire extinguishing systems having the capability of operating both from on-board water and from tender-fed water should be developed as a matter of urgency and introduced at the earliest opportunity on all commercial passenger carrying aircraft.
Issued: 15-DEC-1988	To:	G-BGJL (2)
Research should be undertaken into methods of providing the flight deck crew with an external view of the aircraft, enabling them to assess the nature and extent of external damage and fires.
Issued: 15-DEC-1988	To:	G-BGJL (20)
The balance of effort in aircraft fire research should be restored by increased effort directed towards fire hardening of the hull, the limitation of fire transmission through the structure and the prevention of structural collapse in critical areas. Short term measures should be devised for application to existing types but, in the long term, fire criteria should form a part of international airworthiness requirements.
Issued: 15-DEC-1988	To:	G-BGJL (21)
A requirement should be introduced to ensure that existing external fuel tank access panels which are vulnerable to impact from engine or wheel/tyre failures on aircraft in service are at least as impact resistant as the surrounding structure. The potential risk of damage from debris impacts should be addressed in future by appropriate design reqirements covering debris ejection from engines and/or impact strength requirements for the airframe.
Issued: 15-DEC-1988	To:	G-BGJL (22)
Aerosols with hydro-carbon propellants should be treated in the same way as other cylinders of flammable gas and their carriage on board aircraft controlled accordingly.
Issued: 15-DEC-1988	To:	G-BGJL (23)
A requirement should be introduced to ensure that all portable oxygen bottles carried on board public transport aircraft are fitted with pressure relief valves and are stowed in thermally protected areas, preferably at low level.
Issued: 15-DEC-1988	To:	G-BGJL (25)
The proposed requirement for cabin crew smokehood protection be extended to include training for crew donning and use during aircraft emergency evacuations associated with a fire and/or smoke threat during the evacuation.
Issued: 15-DEC-1988	To:	G-BGJL (26)
The applicable regulatory requirements for aircraft cabin materials certification should be amended at the earliest opportunity to include strict limitations of smoke and toxic/irritant gas emissions.
Issued: 15-DEC-1988	To:	G-BGJL (27)
A research program should be undertaken to establish the effect of water mist/spray extinguishing systems on the toxic/irritant constituents of fire atmospheres.
Issued: 15-DEC-1988	To:	G-BGJL (28)
The existing regulatory requirements governing the Evacuation Certification of public transport aircraft should be reviewed and amended to include: i) A demonstration of an acceptable evacuation time when the cabin is evacuated using half the total number of exits, disposed towards one end of the cabin; that end being chosen which represents the greatest restriction to passenger egress.; ii) Simulation of a defined dense smoke atmosphere within the cabin, existent from the initiation of the evacuation until its completion.; iii) All other sub-testing associated with cabin evacuation, including passenger aisle flow, the identification of exits and aperture egress rates, upon which design and configuration certification decisions are based, be conducted in the same simulated smoke atmosphere.
Issued: 15-DEC-1988	To:	G-BGJL (29)
The design strength of the break-forward \'baulks\' fitted to the seats adjacent to overwing exits should be increased to prevent failure due to passenger pressure-loads on the backs of these seats.
Issued: 15-DEC-1988	To:	G-BGJL (3)
Operators should amend their Operations Manuals, if necessary, to direct crews on any rejected take-off or emergency landing to stop on the runway and review the situation before a decision on clearing the runway is made.
Issued: 15-DEC-1988	To:	G-BGJL (30)
Research should be undertaken to assess the viability of \'audio-attraction\' and other techniques designed to attract passengers towards viable exits when speech and vision is impaired in smoke and toxic/irritant gases.
Issued: 15-DEC-1988	To:	G-BGJL (31)
Research should be undertaken into the effects of cabin airflow on smoke/gas venting and flashover delay/suppression, with a view towards the possible benefits of changing current cabin air-conditioning design and/or associated procedures.
Issued: 15-DEC-1988	To:	G-BGJL (4)
Consideration should be given to the requirement to fit an evacuation alarm permitting flight deck crew to instruct cabin crew to initiate an evacuation immediately, or if the aircraft is still moving to prime for an evacuation immediately the aircraft is brought to a halt.
Issued: 15-DEC-1988	To:	G-BGJL (6)
The Civil Aviation Authority should continue to work with other regulatory authorities to define a mandatory international code of practice for identifying the appropriate method of promulgation for manufacturers\' safety information. This code should include a procedure for ensuring that, at the earliest opportunity, preliminary/advisory information should be followed up and superseded by appropriate Bulletins, Airworthiness Directives or manual ammendments.
Issued: 15-DEC-1988	To:	G-BGJL (7)
If manufacturers are to continue to supply maintenance guidelines which require the operator and his regulatory authority to determine maintenance intervals, particularly for critical components, a re-evaluation should be undertaken of the methods employed to judge residual component lives, particularly following repair.
Issued: 15-DEC-1988	To:	G-BGJL (8)
Direct fusion weld repair of circumferential cracks in JT8D engines combustor cans should be deleted from all approved Engine Overhaul Manuals, unless the safe life of the repaired can has been demonstrated for the anticipated overhaul/inspection period.
Issued: 15-DEC-1988	To:	G-BGJL (9)
Operators should seek the manufacturers comments when making changes to approved technical manuals, under the terms of approval granted by the CAA.

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Photos

accident date: 22-08-1985
type: Boeing 737-236
registration: G-BGJL

Seat map Boeing 737-236 G-BGJL

accident date: 22-08-1985
type: Boeing 737-236
registration: G-BGJL

Plan

Ce plan montre l'aéroport de départ ainsi que la supposée destination du vol. La ligne fixe reliant les deux aéroports n'est pas le plan de vol exact.
La distance entre Manchester International Airport et Kerkyra-I. Kapodistrias Airport est de 2252 km (1407 miles).

Les informations ci-dessus ne représentent pas l'opinion de la 'Flight Safety Foundation' ou de 'Aviation Safety Network' sur les causes de l'accident. Ces informations prélimimaires sont basées sur les faits tel qu'ils sont connus à ce jour.

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