Key Safety Issue(s)

Improper combustor can repair/weld:

Also, see The Left Engine in the Accident Board Findings Section - Items 23-52

See prevailing cultural/organizational factors for a description of the confusion surrounding the type of repairs appropriate for combustor can cracks.

Because of this confusion, British Airtours performed an improper weld on combustor can No. 9, leading to the engine failure which ultimately caused the fuel leak and fatal fire.

Fuel Tank Access Panel design:

The wing-tank access panel had an impact strength approximately one quarter that of the lower wing skin. As a result, when the ejected dome of the No. 9 combustor can and a small section of the fan case struck an under wing fuel tank access panel, a hole was made in this panel which had an area of 42 square inches. Had the dome struck the adjacent skin, penetration of the tank probably would not have occurred. Neither the access panel nor the lower wing skin were designed to any impact resistance criteria, nor were they required to be.

Also, following this accident, the impact resistant panels were originally placed in locations within one-nacelle diameter of the engines, a design criterion typically associated with fire protection, but not generally associated with protection strategies related to tire and rotor burst zones. Subsequently, upon a reevalulation of the protection criteria, the requirement for impact/fire resistance was extended to all locations that fall within the rotor and tire burst zones.

Escape Slide Malfunction:

A design fault existed with the slidebox lid-release lanyard. This fault caused the door to jam during rapid door opening; the door unlocked normally, but as it was moving out through the aperture, the slide container lid jammed on the doorframe, preventing further movement of the door. As a result, the flight attendant was not initially able to open the door, preventing passengers from evacuating through that door. After opening the door on the opposite side of the cabin, the flight attendant returned to the door and was eventually able to open the door and the slide deployed, as designed.

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