Mayday Air Crash Investigations - S09 E01 - Panic on the Runway
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00:00B2L 28, you are clear for takeoff.
00:1480 knots.
00:18Stop!
00:20Don't hammer the brakes. Don't hammer the brakes.
00:24137 people are on board this British Air Tours flight.
00:27Within minutes, nearly half of them will be dead.
00:31This should not really happen.
00:33Evacuate! Evacuate!
00:35The aircraft didn't even get airborne.
00:37It didn't run off the runway, and yet still 55 people were killed.
00:42For investigators, it's a familiar routine.
00:45Reconstructing the final moments inside the cabin.
00:48Analyzing the wreckage and the flight data recorders.
00:52In the end, they turn to a psychologist to help them figure out
00:55how a survivable emergency turned into one of British aviation's most horrific disasters.
01:00Made it, made it.
01:06Remind me.
01:08I'm sorry.
01:10A bad pass.
01:12A bad pass.
01:14A bad pass.
01:18A bad pass.
01:20Analyzing the Wifelh-Header.
01:22It's just before 6 in the morning on August the 22nd, 1985.
01:36Manchester's airport is coming to life.
01:39The first flights of the day are being prepped for departure.
01:42British Air Tours Flight 28 is scheduled to take 131 passengers from Manchester to the Greek island of Corfu.
01:57British Air Tours is a division of British Airways specialising in low-cost flights to vacation destinations.
02:06It's a chilly morning. A slight breeze is blowing. Ideal flying weather.
02:12Most of the passengers on this early-morning flight are travelling on vacation.
02:26Lindsay Davis is heading to Greece with her boyfriend, Charlie Thixon.
02:31All right, let's go.
02:33We'd been going out with each other for a year, and that's one of the reasons we were so excited about it.
02:39You know, it was our first holiday together.
02:43Captain Peter Tarrington is in command.
02:46I was the senior training captain on the fleet.
02:50First Officer Brian Love is being trained by Tarrington.
02:54He was going to perform the take-off and landing as part of his training.
03:00All right, Captain?
03:02Yep. Briefing then, Brian.
03:04Airfield emergencies, you handling the aircraft.
03:06Mm-hm.
03:07What are the four things you're going to stop for?
03:08Fire, failure, configuration, warning, or you shouting stop.
03:11Okay.
03:12So you bring the thing to a stop, and I'll take over the aircraft and leave you to deal with the emergency.
03:16I'll use the ATC.
03:17Okay?
03:19If you've talked about the possibility of the emergency and talked over what you will do, then if it actually happens, it's easier to recall those items.
03:29Okay, Brian, start two.
03:31Starting two.
03:32Oil pressure rising?
03:33Okay.
03:34Go on.
03:35Oil pressure rising?
03:36Okay.
03:37Go on.
03:3825, 26, 27, 28, 29.
03:45129 plus two on board, Captain.
03:47All strapped in doors are closed down automatically.
03:50Thank you, Arthur.
03:52The crew is flying a Boeing 737.
04:05It takes just four minutes for the plane to reach the foot of the runway.
04:11VTours 28, you are clear for takeoff.
04:15The 737 has 3,000 meters to get to takeoff speed.
04:22The engines are pushed to high power.
04:28I was sitting by the window, looking out of the window.
04:31Everything was normal.
04:32The plane was going quite fast.
04:3680 knots.
04:37Check.
04:46We heard a dull thud, which sounded as if it came from outside.
04:53I was really keen to see what was going on outside, but couldn't see anything.
04:58Captain Tarrington needs to act fast.
05:00Stop!
05:05And the immediate reaction was to stop.
05:06We were quite a few knots below our decision speed.
05:07So I very quickly closed the throttles and applied reverse thrust.
05:20We knew we could feel the aircraft slowing down.
05:23And Arthur said, oh, I think we've blown a tire.
05:24And I didn't know.
05:25So we just waited to hear it.
05:26Don't hammer the brakes.
05:27Don't hammer the brakes.
05:28Don't hammer the brakes.
05:29Don't hammer the brakes.
05:30I thought the tire might have gone and would cause damage to the undercarriage if we break
05:34too strongly.
05:35Probably nothing.
05:36Couldn't worry.
05:37I just assumed that maybe a tire had burst.
05:38So I wasn't really alarmed at that point.
05:39My thought at that time was, oh, okay, we're going to get off this plane and probably have
05:44to move all the luggage onto another plane and take off.
05:49Soon passengers on the left side of the plane see the real problem.
06:18I could see orange flames inside the back of the engine.
06:23And at that point I thought, it's obviously not a burst tire.
06:28That wouldn't cause that.
06:29And this is perhaps something a bit more serious.
06:32Let me by.
06:35I'm not staying there.
06:36But at that point I knew that I wanted to get off the plane and I wasn't happy at all.
06:42I knew that there was a fire and I just wanted to get away from the fire.
06:47Smoke is seeping into the cabin.
06:50Please sit down.
06:51My nearest exit was at the back.
06:53I didn't want to go to the back because the smoke was coming in there.
06:56So I decided in my mind that I was going to go through the front.
07:00I said to Charlie.
07:01Come on.
07:02We're going.
07:03And that's when I started going towards the front of the plane.
07:09Stop it.
07:1028, Mike.
07:11We're abandoning takeoff.
07:13Looks like we've got the fire on number one.
07:18Looks like there's a lot of fire.
07:21Plane on fire.
07:22Runway 24.
07:23From where he's sitting, Captain Tarrington can't see how bad the fire is.
07:28He needs advice from the tower.
07:30Do we have to get the passengers off?
07:32I would do by the starboard side.
07:35Tarrington decides to pull off the runway.
07:37Evacuate to the starboard side, please.
07:42Fire rail.
07:43Number one.
07:44Shutting down.
07:45Two.
07:46Evacuate.
07:47Evacuate.
07:48Please stay calm.
07:49Before the flight crew leaves the cockpit, they must complete a 15-step checklist.
08:04Parking brake.
08:05Set.
08:06Speed brake lever.
08:07Down.
08:08But time is running out.
08:10We had an evacuation checklist, but it was four pages long.
08:15And the last item was to get the passengers off.
08:18Engine and APU via warning switches.
08:20This didn't cover my problem at all.
08:23On the 737, there are four cabin doors.
08:28The two in the back are covered in flames and smoke, leaving only two for 137 people.
08:36Then, a mechanical problem eliminates one of those.
08:41Arthur was opening one right.
08:45And, um, it was really bang.
08:46It was really trying to open.
08:47It was really hard to open.
08:48The back of the cabin is filling with smoke.
08:58It's making breathing difficult.
09:00Passengers rush forward.
09:02It just seemed to go on forever before they started evacuating.
09:07And that's when I thought, I'm not going to get off.
09:11It's going to blow up with all of us on it.
09:13Engine and APU fire warning switches.
09:15Engine and APU fire warning switches.
09:16Right now, all 137 people on board are alive.
09:21But with every second, their odds of surviving are decreasing.
09:24Flight 28 is becoming a death trap.
09:30The jammed door on the right side of British Air Tours flight 28 leaves the crew no choice.
09:47They must get the passengers out from the side of the plane that's burning.
09:54As soon as we opened the door, the fire service were already around, shooting foam up the slide and came into the galley floor.
10:06We wanted to start to accurate the passengers, but there was a bit of a bottleneck and nobody was coming forward.
10:14The aisle is quite narrow where the galley is.
10:17And they were sort of pushing forward, and I could see this boy that was really sort of pushed against the wall.
10:29He couldn't get out, so I pulled him by his T-shirt, had the yellow T-shirt on,
10:33and he sort of tumbled forward.
10:36And after that, everybody sort of just tumbled in behind him.
10:41And we just directed him down the slide.
10:48In training, they tell you to, you know, bring people to the door and you tell them to jump.
10:57Desperate to get people off the plane quickly, the purser returns to the jammed door.
11:03After several attempts, he manages to force it open.
11:09The only time I turned around was to make sure that Charlie was following me.
11:13One thing I did see when I looked back was people going to the front, towards the front of the plane,
11:23where the seats are, and pushing the seats forward, folding them down as they went along.
11:29So people were trying to rush forward from the back.
11:33The chute was open, and people were just jumping up straight onto the chute.
11:38As I got to the bottom, I didn't look back at all. I was just wanting to get off.
11:43Dozens of passengers have made it off the plane, but there are still many more inside.
11:49But it was smouldering, and it was black, thick black smoke.
11:53And Charlie had said that after you'd gone, this black smoke came down.
11:58He said, and everybody was screaming and panicking.
12:05He said, people are going to die in there.
12:08Standby power switch.
12:09Captain Peter Terrington and his first officer, Brian Love, are still aboard the burning airplane.
12:14And they still haven't completed the steps required to evacuate.
12:21There was four tons of fuel coming out of that aircraft wing tank.
12:26Go, Brian. Go, Brian.
12:28I can see quite a lot of flames.
12:31Completing the checklist would put their lives at risk.
12:35We did as many items as we could.
12:39And then we both went out of the flight deck window.
12:49There are no more passengers at the exits.
12:53So Joanna Toff decides to see if anyone else is left in the cabin.
12:57The smoke was...
12:59You could touch it. It was so thick.
13:01And you could take... It was awful, really.
13:03No!
13:18There was a young girl, just a bit further down in the cabin.
13:22But she was really disorientated.
13:25I mean, I suppose we all were, really.
13:27We just didn't have any idea what was going on.
13:28So I just brought her down to the slide.
13:33She was taken off the phone.
13:36The fireman was telling me to come by.
13:39And I was thinking, well, I'm not finished.
13:42You know, we've not finished yet.
13:45When Toff re-enters the cabin,
13:48the thick smoke makes it as hard to see as it is to breathe.
13:51It was really dark and quiet. I've never seen anything like it.
13:54And I could see the light from the door anyway by then.
13:56So I knew where the door was.
13:58The smoke forces Toff to abandon her search.
14:00Just minutes after pulling off the runway, British Air Tours Flight 28 has been consumed by fire.
14:13We got out of a flight deck, which was relatively intact.
14:14And when we turned round on the ground, we saw a complete wreck of an aircraft and it had happened in a matter of seconds.
14:18It was dreadful.
14:1954 people are dead.
14:21Another would die in hope.
14:22Another would die in hospital.
14:2354 people are dead.
14:24Another would die in hospital.
14:2554 people are dead.
14:2654 people are dead.
14:27Another would die in hospital.
14:2854 people are dead.
14:2954 people are dead.
14:31Another would die in hospital.
14:3554 people are dead.
14:4454 people are dead.
14:4656 persons are dead.
14:59There was nothing wrong, really, with us.
15:01We thought nothing physical wrong with us.
15:04But our lives changed, you know, just in those few hours.
15:10I couldn't breathe. I was virtually out at all. I couldn't breathe then.
15:26The smoke was coming in and everybody just stood up and ran out. It was just a mad panic getting out.
15:33It was when the smoke came. You just couldn't see anything at all. Couldn't see anybody.
15:37It takes 125 firefighters, more than two hours, to put out the fire.
15:48News of the disaster soon spreads around the world.
15:52British Prime Minister Margaret Thatcher flies to Manchester to visit the scene.
15:57When we get a terrible air crash of this kind, everyone is appalled and shocked.
16:02Every single aspect of this accident will be thoroughly investigated.
16:07It has to be.
16:09This is the fourth major commercial air disaster of the year.
16:13In June of 1985, an Air India jet exploded over the Atlantic Ocean.
16:21329 people were killed.
16:24Weeks later, 137 people died when a Delta Airlines flight crashed at Dallas-Fort Worth Airport.
16:31And just ten days before the Manchester crash, the deadliest single aircraft accident in history.
16:41Japan Airlines Flight 123, a fully loaded 747, slammed into a mountain, killing 520 people.
16:49British Air dangers.
16:55British Air Tours Flight 28 adds 55 new victims to the list of casualties.
17:001985 is now the deadliest year in the history of commercial aviation.
17:05The flying public is getting nervous.
17:07britain's air accidents investigation branch sends a team to manchester to unravel the events that
17:17led to the catastrophe among them stephen moss he'll be inspecting the plane's engines
17:24this should not really have happened the aircraft didn't even get airborne it didn't run off the
17:31runway and yet still 55 people were killed Chris Prothero is also on the team his focus is on the
17:40fire we were aware from initial reports that the fire had entered the the aircraft very rapidly as
17:51the aircraft came to a halt and that that was a focus for me it doesn't take too long for
17:58Stephen Moss to figure out where the trouble started he sees damage to the plane that was not
18:05caused by fire well the first thing we noticed clearly was the the hole in the underside of the
18:11wing and right next to it was a gaping hole in the side of the engine seems that one led to the other
18:28to get a plane loaded with passengers off the ground you need to generate massive thrust that
18:38power is created when air travels through the front of the engine to a series of compressor fans it's
18:44then ignited and the exhaust pushes the plane forward something had clearly gone very wrong with flight 28's
18:53left engine investigators look for clues on the runway and in the cabin hoping to discover why so many
19:07people died entering the cabin for the first time there was a as with all aircraft fires there's an
19:19overwhelming pungent smell burning plastic burnt fuel burning material dropped down onto seats and so
19:29that the aisles were filled up with with the remains of overhead lockers a scene of of devastation the
19:42damage in the cabin is revealing it's almost completely charred up high but is relatively
19:49intact down low it was clear that they had not been a flashover in this particular case
19:56a flashover occurs when the gases and an enclosed space becomes so hot that they ignite incinerating
20:05everything around the way flight 28 cabin is charred tells Prothero about the nature of the fire
20:17many of the seats squab cushions even things like the emergency evacuation cars which is as plastic
20:25laminated cards were pretty much undamaged you could have wiped them off and put them on another
20:32aircraft that nobody would have known they'd been in this accident whereas at the upper levels in the
20:36fuselage there was a great deal of heat damage and this is not a characteristic of a flashover
20:41the fire in the cabin had been severe but should not have been catastrophic this leaves investigators
20:52with two questions why did so many people die and what caused the fire the answer to the second question
21:05may be outside the plane lying on the runway investigators find a large piece of dome-shaped metal along the
21:12plane's path Stephen Moss can see it's from a piece of the engine called a combustor can
21:21it looks like they've been a separation of the can from the front end from the back end the combustion chamber of the 737s jet engines contains nine combustor cans
21:37it's where fuel and air are mixed and ignited so each can needs to withstand intense heat
21:44mass suspects the fractured can somehow blew apart and destroyed the planes left engine it had struck an
21:55underwing fuel tank access panel and put a sizeable hole in that which directly led to the release of a
22:02vast quantity of fuel proving the piece of the combustion can penetrated the way is easy it fits neatly into the
22:11hole in the wing this was clearly if you like the root cause of the accident the engine on the plane is a
22:19Pratt & Whitney JT 8D for Moss that's of grave concern at the time was probably the most widely used jet engine on
22:29commercial air transport in the world and it was obviously pretty urgent that we try and find the the cause of
22:36of this one in order to prevent other aircraft having the same problem there are tens of thousands of
22:44combustor cans in service around the world one of them erupted in Manchester Stephen Moss needs to find
22:54out why it failed and fast investigators looking into the deadly fire on board British air tours flight
23:1028 study the plane's maintenance log they discover the combustor can that ruptured had previously been
23:17repaired we needed to look at that repair and and how effective it was during a routine inspection a
23:29year and a half earlier mechanics had found small cracks in some of the combustor cans it was certainly not
23:44uncommon to find fatigue cracks in the in the cans they're operating in a high temperature environment
23:55the manuals give various schemes for repairing these cracks investigators find mechanics repaired the cracks
24:03according to a procedure laid out in the engine repair manual they welded them closed but the crack on can
24:10number nine was unusually long the overhaul manual did not give any limit on the length of crack that could
24:20be repaired and it was a longer crack that had been experienced before it was still repaired
24:29after the repaired cans were put back in the engine mechanics had no way of knowing the world didn't
24:35effectively seal the crack that's because the cans can't be inspected while the engine is on the plane
24:45since the repair there were 11 reports of slow acceleration from the engine that exploded in Manchester
24:54a damaged combustor can could have been a reason for the problem
24:57but troubleshooting guides available to mechanics in Manchester didn't list that as a potential cause
25:06instead Pratt and Whitney offered other ways to fix the acceleration problem
25:11it didn't seem to ring any great alarm bells with them if you like it's they'd seen it before
25:18and it had never turned out to be anything serious
25:21so mechanics in Manchester made minor adjustments to fix the plane's idle speed and kept the plane in
25:29operation
25:33cockpit voice recordings reveal that the crew of flight 28 was aware there was a problem with slow
25:39acceleration slow acceleration on number one engine day before yesterday i was on the flight yes sir
25:46engineer signed off on it but the log entry led captain terrington to believe that the problem had been
25:51fixed a comment in the tech log for the flight before the last one that the engine was slow in accelerating
26:03it wasn't apparent as a serious problem because the engineers had done some work and the aircraft had
26:09been flying the previous day with no no problems the idle speed adjustments didn't fix the real problem
26:17the cracked combustor can and it reached the breaking point on flight 28
26:25stopping 28 mike we are abandoning takeoff
26:30evacuate evacuate please stay calm and don't panic
26:36if the airline had inspected the cans i think there is no doubt that they would have seen the problem
26:41investigators now know the origins of the manchester disaster
26:51the welded crack in combustor can number nine gave way as flight 28 sped down the runway
26:58the front of the can was ejected from the engine and put a hole in the underside of the left wing
27:03that led to a huge fuel leak onto the damaged engine which caused the fire engine fires are not uncommon
27:12the body of a 737 is insulated with fire retardant material to protect the cabin
27:18investigators still don't understand how a fire outside the plane spread into the cabin as quickly as it did
27:24fire inspector chris protheroe finds part of the answer from viewing photographs of the plane as it sped
27:31down the runway it was clear from these photographs there was a very dynamic phase to the fire whilst
27:37the aircraft was at speed on the runway which produced this energetic turbulent sort of blow torching type of
27:45fire visually anyway trailing behind the aircraft a press photo from the day of the crash leads protheroe to a new
27:53theory the photographs of the aircraft that appeared in the press showed the left thrust reverser deployed
28:04the general impression that one got visually from that photograph was that the thrust reversers had
28:09effectively blow torched fire against the side of the fuselage and that that if you like was the
28:16explanation as to why the fire had penetrated so quickly
28:20that photograph and the implications of it actually um therefore loomed quite large stop there are
28:29several ways to bring a speeding jetliner to a halt one is with the brakes don't hammer the brakes
28:37another is with the engine's thrust reversers thrust reversers redirect the exhaust from the jet engine
28:43forwards this helps slow the plane down it looked as though the thrust reversers had simply blown this
28:52big fire on the left of the aircraft against us directly onto the side of the aircraft directly onto the rear
28:58fuselage that would explain why the fire destroyed the cabin so quickly it now seems possible that captain
29:07terrington made the fire worse by trying to slow his plane down but protheroe has two good reasons to doubt
29:15his theory one is the location where charring from the burning exhaust gas or efflux was found
29:21the efflux impinges on the fuselage further up closer to the roof the crown skins of the of the aircraft so
29:35actually the penetration that we had low down did not fit with that and the other reason is by the time
29:44the thrust reversers were deployed the left engine had already exploded
29:52but to act as a blowtorch the engine would have needed considerable exhaust
29:59we did calculations to confirm that the residual thrust from that engine
30:04would not have had the energy to have this effect that confirmed that the thrust reversers couldn't
30:11actually have played any role or significant role anyway in the in the fire's severity
30:21clearly something other than the thrusters had caused the fire to spread so quickly
30:26protheroe looks more closely at the data
30:29after examining weather reports from the day of the accident he finds the answer
30:33the wind was the main factor that determined the severity of the fire in terms of its attack on the
30:45outside of the aircraft how rapidly it penetrated the aircraft and it also affected the conditions
30:51inside the cabin believing he had blown a tire captain terrington made a fateful decision
30:57stop it 28 mike we're abandoning takeoff well when when we when we heard the thud and we we closed the
31:03thruffles it was my assumption that we were going to turn off the runway clear the runway ask air traffic
31:10for an engineer to come out and check the tires like a highway an airport runway has a series of exits
31:17captain terrington chose one called link delta
31:20and when we got the additional information of a fire warning the brain was already programmed to carry
31:33out the uh the stop the crew had been aware that they had a fire but didn't really appreciate at the
31:42time that the nature of the fire the severity of the fire so they had turned off the runway
31:47captain terrington turned his plane to the right and brought it to a stop
31:54he couldn't have realized that doing so would make the problem far worse
31:59there was a crosswind a slight crosswind from the left side of the aircraft
32:04that was carrying the fire that was burning from the fuel that was pulled underneath the left wing it
32:11carried that fire aft rearwards and took over and under the rear fuselage in between the wing and the tail
32:20plane the wind wrapped the fire around the back of the plane and into the cabin
32:29if there'd been no wind at all i think the situation would have been very much more benign
32:33investigators have discovered how the fire started and the conditions that caused it to penetrate the cabin
32:46now investigator ed trimble must solve the biggest mystery surrounding the manchester accident
32:51here we had an aircraft which had aborted the takeoff for good reason had taxied off and stopped in a taxiway
33:05in an expeditious manner and yet 55 people had lost their lives so there was a big question as to
33:14precisely why that had occurred
33:19investigators learned that most of the dead were not found in the worst burned parts of the plane
33:28autopsies will point to the real killer on flight 28
33:31of the 54 people who died in the cabin only six had suffered serious burns all the rest died from smoke inhalation
33:48it seems the smoke in the cabin was particularly lethal survivors tell investigators that the smoke was
33:55unbearable the smoke was really black and and it was it was it was almost touching it was it was really weird
34:04and they say the effect of that was shocking immediately you took one breath of the smoke
34:10you began to feel debilitated and you knew that if you took another breath or two you weren't going to make it
34:16at the time of the manchester accident the effects of fire on an airplane had been well studied and
34:26understood but the effects of smoke were not
34:33to figure out what made the smoke so toxic trimble decides to recreate the fire that burned on flight 28
34:39we were trying to model not only the gases which were produced but also the kind of threat levels
34:48which were produced the smoke that filled the plane was from materials burning inside the cabin
34:54the foam in the seats the wool in the carpets and the plastic overhead bins all release poisonous fumes
35:02those conditions are recreated by burning those same materials
35:08trimble discovers the passengers on flight 28 inhaled smoke that contained a deadly blend of poisonous gases
35:16including high levels of carbon monoxide and hydrogen cyanide
35:24now he desperately needs to find out if there's any way to protect airline passengers from that kind of smoke
35:32so it seemed to be pretty clear that unless we could protect people's respiratory systems from the assault
35:42from such combustion gases there was little that we could do to improve survival chances from aircraft fires
35:51over the course of five weeks investigators run dozens of tests experimenting with different filters
36:12they burn nearly a quarter ton of material to create the necessary smoke
36:17their dramatic conclusion it may have been possible to save passengers lives
36:23there was not the slightest doubt in my mind that in these situations in an aircraft cabin if it is
36:29being assaulted by combustion gases your chances of survival are vastly improved if you have smoke hood protection
36:41British air tours flight 28 had only enough smoke hoods for the crew they were never used
36:56trimble's research indicates that smoke hoods for passengers could have saved lives
37:00there were hoods available both of the filter type and the breathable gas type which can provide a very high
37:08level of protection to people in these circumstances
37:11many of the passengers on flight 28 would have survived with a few more minutes of breathing time
37:26it was it was in a blink of an eye you know from from the time you know we stopped on the runway
37:33you know just within a few minutes it was all over really
37:41a full boeing 737 is designed to be evacuated in less than two minutes
37:46so even without additional time more of the passengers on flight 28 should have been able to get off
37:56to discover why so many people never made it off the plane
38:00investigators turn to an unlikely source for the answer
38:12by law airplane manufacturers must prove their planes can be evacuated quickly and safely
38:18when the 737 was introduced in the uk boeing demonstrated that 130 people could get off the
38:24plane in just 75 seconds all public transport aircraft are certificated to the same criteria and that is
38:32that the total complement of passengers must be capable of evacuating from the aircraft using half
38:41the exits in the aircraft as channel one side or the other within a maximum of 90 seconds but 90 seconds
38:48after flight 28 came to a stop most of the passengers were still on board
38:58the reason why the evacuation in manchester wasn't achieved in 90 seconds is because the conditions
39:06in a real fire evacuation are completely different from the certification conditions
39:11the certification evacuation is conducted in clear conditions with no smoke that produces vision and
39:18overwhelms passengers
39:22within minutes of coming to a stop flight 28 filled with thick black smoke
39:27as soon as the smoke began to spill into the rear cabin and then flow forwards
39:37essentially that induced immediate panic
39:40in those who were so affected by the smoke because their respiration i mean the typical comment was i took
39:46one breath of smoke and i felt as though my lungs were solidified you can imagine under these conditions
39:52that people have got to get away from the smoke and people did this by basically clambering over the seats and other people in front of them
40:03in less than five minutes what should have been a survivable accident turned deadly
40:11to prevent future tragedies britain's civil aviation authority decides to learn more about people helen muir is
40:18a psychologist and a leading expert on how airplane design can influence survival
40:25she's asked to study the behavior of passengers on flight 28 to figure out why so many died
40:34what we had to learn to do was to design the aircraft interior so even if we had
40:39what we might say was dysfunctional behavior in totality we could accommodate the needs of individuals
40:46and they're desperate rush to get out muir configures a cabin to duplicate flight 28
40:54and fills it with volunteers then to have them act as though the plane's on fire
40:59she offers money to the first ones off and that produced behavior that was quite unbelievable people
41:06went over seats they went round past each other all sorts of things and indeed when survivors from the
41:12actual manchester accident came and saw the videos they said yeah this is that's how it was
41:28the evacuation of flight 28 was slowed by the fact that passengers became jammed in
41:33the bulkhead opening separating the main cabin from the galley
41:36the bulkhead opening was 22 and a half inches wide just enough for one person to fit through
41:54but what they wanted to know was how much wider would they have to make it for people not to get
42:00stopped and blocked we were trying to do as much as we could to recreate the situation which had
42:06happened at manchester and then to systematically vary the aircraft interior to see what changes would
42:13improve the situation for passengers muir's tests showed the narrow bulkhead opening created bottlenecks
42:20that flight attendants had to constantly clear increasing the width to 30 inches greatly improved the movement
42:27of passengers
42:32but we showed through repeat testing that if you changed the minimum gap from 20 to 30 inches you would
42:39dramatically improve the speed at which people could get out and you'd reduce the likelihood of
42:45people falling and slipping and so on as a result of helen muir's work a recommendation was made to
42:52increase the space between the bulkhead walls to 30 inches and introduce strip lighting to help guide
43:00passengers to exits even when they are blinded by smoke
43:07muir also found a way to improve cabin safety without redesigning the cabin
43:13please sit down she conducted research on the behavior of the cabin crew in emergencies
43:18and found that passengers get off a plane much faster with a highly assertive crew
43:29it's because we don't want people really making their own decisions we want people to do exactly what
43:37the cabin crew or the procedure state and we don't want people hesitating particularly at the door
43:43we don't want people helen muir's research prompted manufacturers to redesign cabins to make them safer
43:50but one safety feature remains controversial smoke hoods
43:57ed trimble believes they should be mandatory on all commercial flights
44:02without a doubt without a doubt
44:05helen muir is less convinced
44:07she studied how smoke hoods affect passenger behavior and is worried they would slow down the
44:14orderly evacuation of an airplane we know you've only got literally one and a half to two minutes for
44:22everybody to get out what we don't want to have is something which is difficult to put on and so it
44:28slows people getting down the most important lesson of british air tours flight 28 is that seconds matter
44:36it's now universally accepted that it takes 90 seconds from the first sign of fire before it becomes unsurvival
44:46the passengers on flight 28 lost valuable time when the starboard side door jammed
44:52the investigators determined that the slide mechanism deployed too early preventing the door from opening
44:58there was a floor that led the slide containers lid to jam if the door is open too quickly
45:06after the manchester accident boeing quickly redesigned the system so that couldn't happen
45:11but the recommendations made by the aaaib weren't adopted quickly enough to save lives six years later
45:20in 1991 a boeing 737 slammed into another plane on the runway in los angeles and caught fire
45:33many of the 22 people who died were overcome by smoke before they could get out
45:38but in 2005 the crash of an air france jet in toronto showed how much has changed since the manchester accident
45:47all 309 people got off that plane in just 90 seconds no one died
45:56some major changes to commercial airliners
46:05all right the door's open came about because of a flight that never left the ground
46:10that's the only way i can resolve it with the the death of 55 of my passengers the fact that
46:20flying is now safer i can't imagine anybody you know doesn't wish that it hadn't happened
46:29you know despite what's been learned and despite maybe the subsequent lives that have been changed
46:35you know you'd give anything for it not to a heart