Description

On 19 August 1980, a Lockheed L1011 operated by Saudi Arabian Airlines took off from Riyadh, Saudi Arabia. Seven minutes after the take off an aural warning indicated a smoke in the aft cargo compartment. The crew spent 5 minutes 20 seconds confirming the first fire warning before the Captain elected to return to Riyadh. The thrust lever for the number 2 engine (center engine) became stuck as the fire burned through the operating cable, and the engine was shut down on final approach. The aircraft returned to Riyadh and executed a safe landing. After touchdown, the L1011 continued to taxi, and stopped on a taxiway 2 minutes 40 seconds after landing. The engines were not shut down for another 3 minutes and 15 seconds, preventing the rescue from reaching the aircraft. All 301 persons on board perished due toxic fumes inhalation and uncontrolled fire.

Synopsis

The following is an extract from the official report of the accident published by the Presidency of Civil Aviation, Saudi Arabia:

"The initial climb toward Jeddah was uneventful until […], 6:54 minutes after take-off [approximately 24 minutes before the airplane came to a stop back at Riyadh]when the flight crew was alerted by both visual and aural warnings indicating smoke in the aft cargo compartment (C-3).

The confirmation time (total 5 minutes and 20 seconds) of the first fire warning before a decision was made to return to Riyadh included also Flight Engineer entering the passenger cabin to investigate the situation. When he returned to the flight deck he reported smoke and fire in the cabin. The airport at Riyadh was contacted, and informed that the airplane was returning because of a fire in the cabin and requested that crash, fire, and rescue be alerted.

After turn back to Riyadh, the flight engineer returned to the passenger cabin to assess the extent of the fire. Upon return to the flight deck he reported there was just smoke in the aft end of the aircraft. This was approximately 17 minutes before the airplane came to a stop after landing. A flight attendant reported to the flight crew that there was a general panic among the passengers. Fourteen minutes prior to landing at Riyadh, another aural smoke detector warning occurred, and was recorded on the cockpit voice recorder (CVR). Thirteen minutes before the airplane came to a stop, the Captain stated that the throttle of No. 2 engine was stuck, and that he was going to shut the engine down. Also, at 13 minutes before the airplane came to a stop on the taxiway, another flight attendant reported she could not go further aft than doors L2 and R2 because people were fighting in the aisles. Immediately thereafter, another flight attendant came into the flight deck and reported fire in the cabin. At 11 minutes before the airplane came to a stop, the CVR recorded an announcement by the cabin crew to stay calm and to stay seated. Ten minutes before stopping on the taxiway, a flight attendant came forward and advised the crew, "there is too much smoke in the back." The flight attendant repeated instructions to the passengers to stay in their seats to prepare for landing. Three minutes 33 seconds before the airplane came to a stop another aural smoke detector warning was recorded on the CVR.

A flight attendant repeated instructions to the passengers to stay in their seats to prepare for landing. The aircraft did not make an emergency stop but instead taxied off the runway to a taxiway. Two minutes forty seconds after landing, the aircraft came to a stop on the taxiway. After stopping, a witness parked his car just behind and to the left of the aircraft. He observed a fire through the windows on the left side of the cabin between the L3 and L4 doors. He said there was no fire outside the aircraft at that time. He could not see any movement in the cockpit or cabin.

Immediately after stopping, an announcement was made to the tower “We are shutting down the engines and are now evacuating”.

One and a half minutes after stopping the control tower relayed to the aircraft that the tail of the airplane was on fire. The aircraft responded, "Affirmative, we are trying to evacuate now". This was the last transmission received from the aircraft.

To view Saudi Arabian Airlines L1011 Flight Path Animation, click here. The animation is a courtesy of FAA Lessons Learned from Transport Airline Accidents (http://lessonslearned.faa.gov/).

Three minutes and fifteen seconds after the aircraft stopped the engines were shut down. Smoke rose from the top of the fuselage, followed almost immediately by flames.

"Attempts by the crash, fire, rescue personnel (CFR) to enter the aircraft and open the doors were unsuccessful until the No. 2 door on the right side of the aircraft was opened […] about 23 minutes after all engines had been shut down."

In a section of the Report titled “The Flight Actions by the Crew” (page 69) it is stated:

[…] "The Captain should have instructed his cabin crew to prepare for an evacuation immediately upon landing. He should have called for the use of oxygen by his cockpit crew and instructed his cabin crew to use oxygen when needed. The inhalation of toxic gasses, at times, is insidious and causes physical and mental impairment which would be alleviated by the proper use of oxygen. […]

[…] After landing, the Captain should have stopped his aircraft as soon as possible and initiated an emergency evacuation. However, he wasted critical time in taxiing the aircraft clear of the runway."

The investigation determined that the C-3 cargo compartment on the L1011 (Figure 1), which was certified as a Class D (per 14 CFR part, § 25.855), did not contain the fire within the cargo compartment as intended by the regulations. The regulations intended that the liner material contain the fire within the cargo compartment, and the fire would quickly consume the oxygen (oxygen starvation) within the compartment before the fire had a chance to get out of control. Testing demonstrated that the Nomex cargo liner fabric material was inadequate to contain the fire within the cargo compartment. As a result of the fire burning through the cargo liner, creating a breach into the cabin, additional oxygen was available to feed the fire in the cargo compartment. The fire quickly spread to the passenger cabin, and the burning material produced toxic fumes, including carbon monoxide.

As to Probable Cause to the accident, the Report states:

"The Presidency of Civil Aviation determines that the probable cause of this accident was the initiation of fire in the C-3 cargo compartment. The source of the ignition of the fire is undetermined.

Factors contributing to the final fatal results of this accident were:

• the failure of the Captain to prepare the cabin crew for immediate evacuation upon landing, and his failure in not making a maximum stop landing on the runway, with immediate evacuation,
• the failure of the Captain to properly utilise his flight crew throughout the emergency
• the failure of CFR headquarters management personnel to ensure that its personnel had adequate equipment and training to function as required during an emergency."

The Presidency of Civil Aviation, Saudi Arabia, made six recommendations regarding the operational practices of the airline. A complete list of recommendations is found in the full accident report, page 78. (see Further Reading).

The recommendations covered a number of subjects:

• Revision of training programs for aircrew, stressing emergencies and command training
• Additional assertiveness training for junior flight crew members
• Crew matching to ensure cockpit experience levels
• Avoid rehiring of flight crew members who have been previously dismissed due to substandard performance
• Review and amend emergency checklists

In addition the National Transportation and Safety Board (NTSB) issued a recommendation to re-evaluate the "Class-D" certification of the L1011 C-3 cargo compartment with a view toward either changing the classification to "C", requiring detection and extinguishing equipment, or changing the compartment liner material to ensure containment of a fire of the types likely in the compartment while in-flight.

Related Articles

FIRE

• Passenger Cabin Fire
• In-Flight Fire: Guidance for Flight Crews
• In-Flight Fire: Guidance for Controllers
• Accident and Serious Incident Reports: FIRE

HF

• Crew Resource Management
• Pilot Incapacitation

Further Reading

• Aircraft Accident Report Saudi Arabian Airlines, L1011, Riyadh Saudi Arabia, 19 Aug. 1980, by Presidency of Civil Aviation, Saudi Arabia (Large file, 45Mb)
• see also FAA Lessons Learned from Transport Airplane Accidents: Saudi Arabian Airlines, Flight 163, Lockheed L-1011, HZ-AHK