The Weekly Reflektion Week 52 / 2019

This week’s Reflektion concerns an aircraft disaster that had an impact on all our flights today.

Do you know why they brief those near to escape exits how to open the doors? Or why there is such excellent legroom at these exit seats? It has not always been like that!

22nd of August 1985, was a ‘defining moment in the history of civil aviation’. A charter flight to Corfu aborted its take-off and caught fire at Manchester Airport and 55 passengers were killed. Changes made after this disaster have had a visible effect on air travel as we know it today.

The aircraft was full of holiday makers without a lot of experience of flying. As the plane accelerated during take-off, a loud ‘thump’ was heard, and the pilot immediately made the decision to abort the take-off, thinking that the plane had experienced a puncture. In fact, the left engine had suffered an ‘uncontained failure’. A ‘combustor can’ had shattered into several pieces, one of which had punctured the wing tank, causing a significant fuel leak. Fire alarms were triggered 9 seconds after the ‘thump’, and 10 seconds later the tower confirmed the fire, and recommended an evacuation from the right side of the aircraft. The aircraft pulled off the runway and stopped to evacuate. The flight attendant tried to open the front right exit door, but it jammed due to a design fault, so the front left door was opened and the slide deployed. Two fire engines arrived and showered the fuselage to cool the aircraft and prevent fire in the cabin. Passengers exiting at the front of the plane became jammed in the narrow passageway leading to the door, causing a delay in the evacuation. More difficulty was experienced exiting through the right over-wing exit. The passenger seated by the exit door did not know how to open the door, causing delay. When the door was eventually opened, it fell onto the passenger trapping him, and blocking the exit.

The seat rows at the exit were spaced as the rest of the aircraft, with 27cm (10,5”) gap, also hindering escape. As smoke and flames filled the cabin, passengers began to panic, and the aisle became blocked with bodies. The man who had been seated adjacent to the right overwing exit door was later found dead, lying across the exit. Most of the bodies were found clustered around the over-wing exit, with smoke inhalation being the cause of death.

The findings of the investigation led to changes in the seating layout around exit doors, briefings for the passengers sitting close to the exits to explain what to do in the case of emergency, floor lighting, clearer instructions for passenger evacuation, and general use of fire resistant materials inside the plane. With the benefit of hindsight, it seems strange that these improvements were not identified earlier, but unfortunately, it often takes a major accident before we recognise the need for changes.

When the flight attendant asks you to keep your hand luggage off the floor around the emergency exits, or asks if you can operate the door, or points out the floor lighting, just be aware that there is a good reason.

Changing the standards and procedures used in industry is one of the methods we use to incorporate learnings from major accidents. Implementing these changes effectively is essential to prevent similar occurrences in the future. However, if we don’t understand why the standards and procedures are there and why they are required, we may be tempted to ignore them or deviate from them. Be careful, these requirements are there for a reason and often people have paid for these learnings with their lives.

Reflekt AS