- British Airtours B737 at Manchester, UK
- Accident Overview
- Accident Board Findings
- Accident Board Recommendations
- Relevant Regulations / Policy / Background
- Prevailing Cultural / Organizational Factors
- Key Safety Issue(s)
- Safety Assumptions
- Resulting Safety Initiatives
- Airworthiness Directives (ADs) Issued
- Common Themes
- Related Accidents / Incidents
- Lessons Learned
- British Airtours B737 at Manchester, UK
Photo of British Air Tours 737
British Airtours Flight KT28M, a Boeing Model 737-200 series airplane, was a charter flight from Manchester, UK to Corfu (a Greek Island).
There were 131 passengers and six crewmembers on board. At 0608, the flightcrew was cleared to taxi to Runway 24 for departure. At 0612, the airplane had lined up on the runway and was cleared for takeoff.
The takeoff was to be performed by the first officer. During the takeoff run, the captain made the routine "eighty knots" call and twelve seconds later a "thump" or "thud" was heard. The captain immediately ordered "stop," closed the throttles, and selected reverse thrust. The maximum speed achieved was 126 knots indicated airspeed (IAS). The “thump” heard by the pilots was the sound of an uncontained failure of the left engine. Debris from the failure punctured a wing tank access panel. Fuel leaking form the wing ignited and burned as a large plume of fire trailing directly behind the engine.
The captain initially believed they had suffered a tire burst or a bird strike. The first officer had applied maximum wheel braking, however, because of the possible tire burst, the captain said "Don't hammer the brakes; don't hammer the brakes." At 45 seconds after the start of the takeoff run, nine seconds after the thud, as the airplane decelerated through 85 knots, the captain radioed Air Traffic Control (ATC) that they were aborting takeoff. The fire bell rang simultaneously and the captain added, as he cancelled reverse thrust, "It looks as though we've got a fire on No. 1." ATC confirmed this, stating, "Right, there's a lot of fire; they're on their way now." At 25 seconds past the thud, and 20 seconds before the airplane stopped, the crew decided to evacuate via the right-hand side of the airplane. The Model 737 was decelerating through 36 knots then and the captain warned the cabin crew about the evacuation six seconds later.
Diagram of Manchester Airport Runway
After the airplane stopped, a No. 1 engine fire drill was carried out. The No. 2 engine was shut down and the passenger evacuation drill was carried out. Before completion of this drill, the captain saw fuel and fire spreading forward on the left-hand side of the airplane. Both the captain and first officer escaped through the sliding window in the right-hand side.
Photo of British Air Tours Engine Fire on Runway
Immediately after the thud, an intense fire developed on the left-hand side of the airplane, 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 forward door (R1) but the escape slide container jammed on the doorframe, preventing further movement of the door. He then crossed to the left forward (L1) door and opened it (25 seconds had passed since the airplane 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 airplane had stopped. Meanwhile, passengers had managed to open the right over-wing exit. The right rear (R2) 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 right over-wing exit.
As the airplane turned off the runway, a wind of seven knots from 250° carried the fire onto and around the rear fuselage. After the airplane stopped, the hull was penetrated rapidly and smoke, possibly with some flame transients, entered the cabin through the right rear door which was opened shortly before the airplane came to a halt. Subsequently, fire developed within the cabin. Despite the prompt attendance of the airport fire service, the airplane was destroyed and 55 persons on board lost their lives.
Photos of Access Panel Penetration
The resulting fire developed catastrophically, primarily because of adverse orientation of the parked airplane 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 airplane cabin, the vulnerability of the airplane hull to external fire, and the extremely toxic nature of the emissions from the burning interior materials.
Photo of Cabin Looking Forward
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 under-wing fuel-tank access panel. The fire which resulted developed catastrophically, primarily because of adverse orientation of the parked airplane 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 airplane cabin, the vulnerability of the airplane 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 right forward door malfunction and restricted access to the exits.