British Airtours flight 328
Boeing 737-200, G-BGJL
Manchester Airport, UK
7:13 am British Summer Time
22 August 1985
Social media was yet to be invented but aviation safety was a trending topic in August 1985. On the second day of that month, Delta Airlines flight 191 had crashed on landing in the US after encountering what was later identified as a microburst downdraft, killing 136 people. And on 12 August, Japan Airlines flight 123 crashed after a structural failure, killing 520, in what remains the world’s most deadly single-aircraft disaster.
Estimates of some level of fear of flying in the general population range between 2.5% and 40% so it’s likely these stories would have been playing on the minds of at least a few of the 131 passengers onboard the package holiday flight from Manchester to Corfu, Greece.
John Beardmore felt more discomfort than fear in his cramped seat on British Airtours flight 328. ‘I remember thinking, “This is going to be an uncomfortable flight”,’ he told the Manchester Evening News in 2015. His wife and 2 sons were in the left seats of the same row.
On the flight deck, first officer Brian Love was preparing to take off after captain Peter Terrington had lined up the aircraft on runway 24, using the left-side only nosewheel steering. They had noted a maintenance issue from the aircraft’s technical log, as part of the pre-take-off briefing. The left engine had been developing less power than the right one at an identical throttle setting.
Looks like we’ve got a fire on No 1.
As Terrington advanced the throttles in response to Love’s command for take-off power, he commented the left engine acceleration seemed acceptable. But at 126 knots, 20 knots below V1, there was a noise from the left described as a thump or thud. Terrington said ‘stop’, closed the throttles, selected reverse thrust on both engines and checked the spoilers were extended.
Love was pressing the toe brakes but with plenty of runway ahead, Terrington, suspecting a blown tyre, said, ‘Don’t hammer the brakes.’ As Terrington was calling the tower to notify of the abandoned take-off, the fire bell sounded. ‘Looks like we’ve got a fire on No 1,’ Terrington said, correctly. A brief exchange with ATC about the size of the fire on the left engine followed and Terrington decided to evacuate only from the starboard (right) side.
Passengers on the left rear side of the cabin already knew they would not be using that door to evacuate. They could see flames and thick black smoke coming from the left wing. ‘At that point I knew there was a serious problem,’ Beardmore said.
Later investigations found a cracked (and repaired) combustion can on the Pratt & Whitney JT8D turbofan had exploded and gone through an access panel in the wing, setting the fuel on fire. The cast aluminium panel had an impact strength only one quarter that of the lower wing skin, which formed the tank floor. This external fire became hot enough after a few seconds to trigger the internal engine fire alarm.
Evacuation appears to have begun before the aircraft stopped but had been orderly at first. ‘Passengers got out of their seats and went towards the exit at the front on the side not affected, they behaved very well indeed,’ Beardmore told the newspaper. His wife and sons were among these.
In an action that would haunt him for the rest of his life, Terrington steered the aircraft onto a taxiway. A cabin crew member opened the right rear door but when the purser attempted to open the right forward door, the top of the escape slide opened too soon and jammed the doorframe. The purser then opened the left forward door.
In an action that would haunt him for the rest of his life, Terrington steered the aircraft off to the right of the runway.
A six-knot wind was now blowing the flames towards the rear of the fuselage and a bottleneck developed at the galley bulkhead at the front of the passenger cabin. A passenger attempted to open the right overwing exit but in 1985, passengers in exit row seats were not selected or briefed and, after a fumble, the door fell inwards onto her companion. Smoke rapidly filled the rear of the cabin and no-one escaped from the right rear exit. The purser managed to open the right forward door after the escape slide was cleared but the bulkhead choke point meant the 2 exits were no faster than one.
By now passengers were collapsing or crawling over seatbacks, swelling the scrum near the bulkhead. A survivor recalled seeing tongues of flame shooting into the cabin through the left-side windows and saw people sitting near these windows engulfed in fire. However, most victims died from toxic smoke inhalation, which acted with horrific speed. The accident report said, ‘A male passenger from seat 15C recalled taking one breath which immediately produced “tremendous pain” in his lungs and a feeling that they had solidified.’
Beardmore said, ‘I started to choke and my knees went, I just saw white air. I thought it was a window and made my way towards it – it was the front door, there was a chute in front of me and I went down it.’
Others died centimetres from safety – investigators found a cluster of bodies near the right overwing exit.
By now passengers were collapsing or crawling over seatbacks, swelling the scrum near the bulkhead.
Post-mortem
The official report published in 1989 by the British Air Accidents Investigation Board contains a grave summary:
Many of the factors which affected this accident should have biased events towards a favourable outcome. The cabin was initially intact, the aircraft remained mobile and controllable and no-one had been injured during the abandoned take-off. The volume of fuel involved, although capable of producing an extremely serious fire, was relatively small compared with the volume typically carried at take-off, the accident occurred on a well-equipped major airport with fire cover considerably in excess of that required for the size of aircraft and the fire service was in attendance within 30 seconds of the aircraft stopping. However, 55 lives were lost.
The report went on to say the ‘early penetration of fire into the cabin’ had conflicted with the air transport industry’s expectations (at that time) of survival in a pooled-fuel fire. ‘The general expectation appears to have been that, with an initially intact fuselage, a period of between 1 and 3 minutes would be available for evacuation before the external fire was in a position to directly threaten the occupants,’ it said.
Most victims died from toxic smoke inhalation, which acted with horrific speed.
The 737-200’s compliance with the 90-second passenger evacuation standard established in the 1960s had been of little help.
Expectation and training had also influenced the crew’s actions which the investigators took particular care to put into context.
‘Their initial assessment of the problem and their subsequent actions were entirely reasonable based on the cues available to them,’ the report said. ‘The decision to turn off was a critical factor in the destructive power of the fire. However, in the context of the knowledge, training and operating practices current at the time of the accident, it is considered that this decision should not be criticised.
‘There is no doubt that this crew, and indeed the aviation community at large, were quite unaware of the critical influence of light winds on a fire, and they did as most other crews would have done faced with a similar predicament.’
This exoneration was unable to assuage Terrington’s anguish. His wife told the Manchester newspaper he spoke of the tragedy every day until his death in 2016. Beardmore views him as the 56th victim.
If the burn-through time could have been delayed by just 50 seconds, it is likely that all the passengers in the Manchester aircraft accident could have safely evacuated.
Change
The installation of escape path lighting on the floor of passenger cabins has often been quoted as a result of the Manchester disaster. However, this development was already under way at the time, and the report cast doubt on its effectiveness, saying, ‘The net safety gains from such a requirement are likely to be minimal unless the passengers’ eyes are protected.’ The report recommended smoke hoods for passengers, automatic audio-attraction devices to guide evacuees towards viable exits and a water misting system for the cabin, none of which were adopted.
The previous emphasis on combustion resistance had not considered the toxicity of cabin seat and trim materials, and new standards covering these were introduced. By 1989 the US Federal Aviation Administration (FAA) required strengthening of aircraft fuel tank access covers from ‘tyre fragments, low-energy engine debris or other likely debris’. The FAA also established new design and construction requirements for emergency exits and established new lighting and interior and exterior marking standards for emergency exits.
A simulated hell
In 2017 an expatriate Australian academic, Professor Ed Galea, Director of the Fire Safety Engineering Group at the University of Greenwich in London, published a paper describing a mathematical simulation of the Manchester fire and evacuation, with co-authors Zhaozhi Wang and Fuchen Jia. They simulated the fire and evacuation taking into account factors such as flame and smoke spread, toxic gas generation and human behaviour during evacuation.
The simulation suggested the number of deaths could have been reduced by 87% (48 people) had the forward right exit not malfunctioned and by 36% (20 people) had the right over-wing exit been opened without delay.
Aircraft structural fire resistance was vital. ‘If the burn-through time could have been delayed by just 50 seconds, it is likely that all the passengers in the Manchester aircraft accident could have safely evacuated,’ Galea and colleagues concluded.
A new hazard: rolling in the aisles
A paradoxical aspect of the Manchester disaster is a problem that did not happen: the purser told the inquiry that passengers were not carrying any ‘noticeable or unacceptable hand baggage’.
It might be tempting to declare that people in the 1980s – or people from Manchester – were more noble than 21st century airline travellers, but there is a simpler explanation. The now-ubiquitous wheeled cabin bag had not been invented in 1985. It would be another 2 years before US airline pilot Robert Plath added wheels and an extendable handle to his flight bag and 6 years before the product went on sale – and changed aviation.
By the 21st century, aircraft overhead lockers were being redesigned to accommodate larger wheeled cabin bags. Low-cost airlines, whose pricing model included extra charges for checked baggage, became dominant in many airline markets, and a further factor emerged with video cameras in mobile phones. Passengers attempting to take cabin bags with them or filming the incident have become a worrying feature of recent aircraft evacuations.
In 2024 Galea and colleagues at the Fire Safety Engineering Group measured this problem. They ran a set of 4,000 computer simulations of luggage retrieval during aircraft evacuation. The experiment found if 25% of passengers evacuating a 180-passenger single-aisle aircraft attempted to take their luggage, evacuation times increased by 11.7%. It took 38.6% longer to evacuate if 50% of passengers went for their bags and 64.3% if 75% took their luggage.
This century has seen some remarkably successful aircraft evacuations from burning aircraft. These fortunate travellers owe their lives at least in part to the improvements made after Manchester. In that sense, flight 328’s victims did not die in vain. But progress can be blocked – literally and figuratively – by something as small and banal as a wheeled suitcase.
The legacy of British Airtours flight 328:
- hardening of wing access panels
- extra space at exit rows
- selection and briefing of exit row passengers
- new standards for cabin materials.
Further information
E. R. Galea, Z. Wang and F. Jia, Numerical investigation of the fatal 1985 Manchester Airport B737 fire, The Aeronautical Journal, volume 121, issue 1237, March 2017, pp. 287–319. DOI: https://doi.org/10.1017/aer.2016.122
E.R. Galea, P.J. Lawrence, D. Cooney, D. Blackshields and L. Filippidis, Investigating the impact of retrieval of carry-on luggage by passengers on aircraft evacuation using the airEXODUS aircraft evacuation simulation software, University of Greenwich Fire Safety Engineering Group / Federal Aviation Administration Report Number: DOT/FAA/24/19, Published: 2024-10-01. DOI: https://doi.org/10.21949/1529674
