Common Themes

Organizational Lapses

Lack of communication between the engine manufacturers and British Airtours related to combustor can repair, and the consequences of performing what was revealed to have been an inappropriate repair - see discussion in organizational/cultural factors and key safety issue(s).

Fire Fighting - see discussion in organizational/cultural factors.

Improper combustion can repair - see discussion in organizational/cultural factors and key safety issue(s).

Flawed Assumptions

British Airtours assumed that the type of weld used for the combustor can repair was appropriate for that application, when in fact the engine manufacturer knew that it was not.

Unintended Effects

The cabin address system volume was linked to left engine operation. During normal revenue service, the volume needed to be reduced when engines weren't operating. However, during the accident when the left engine failed, the decibel level of the cabin address system automatically dropped to a lower level; as a result the captain's call for evacuation was not initially heard.

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