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South African Airways 295

Accident Case Study

 


 

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South African Airways 295 wreckage, from FAA Lessons Learned.

Accident Report

  • Date: 28 November 1987
  • Time: 00:07
  • Type: Boeing 747-244B
  • Operator: South African Airways
  • Registration: ZS-SAS
  • Fatalities: 19 of 19 crew, 140 of 140 passengers
  • Aircraft Fate: Destroyed
  • Phase: En route
  • Airports: (Departure) Taipei-Chiang Kai Shek International Airport (TPE/RCTP), Taiwan; (Destination) Mauritus-Plaisance International Airport (MRU/FIMP), Mauritus

Narrative

South African flight 295 took off from Taipei at 14:23, carrying 159 occupants and 6 pallets of cargo in the main deck cargo hold. At 23:49 the crew reported Mauritius Approach control they had a fire on board. An emergency descent to FL140 was carried out. Mauritius ATC cleared the aircraft to FL50, followed by a approach clearance. The captain's response was the last radio contact with SA295. It appeared that a fire had started in the cargo pallet at position PR. The aircraft had somehow lost control, broke up and crashed into the Ocean.

[FAA Lessons Learned]

  • More than nine hours into the flight and only about 45 minutes before expected arrival in Mauritius, the flight crew reported smoke to Mauritius Approach Control (MRU) and proceeded to declare an emergency. The airplane's fire detection system had detected smoke in the Class B cargo compartment, and an audible alarm was provided in the cockpit. This alarm could be heard on the airplane's cockpit voice recorder (CVR) tape, which was reviewed after the accident. The alarm likely occurred shortly before Flight 295 contacted MRU to report the smoke. Unfortunately, the CVR and the wiring to it were located in the vicinity of the Class B cargo compartment, and damage from the fire rendered the CVR inoperable within eighty seconds after the audible alarm can be heard on the tape. As such, determining precisely how much time elapsed between the alarm and when contact with MRU was made was not possible because the contact with MRU was made after the CVR failed. The time was probably a matter of minutes, during which the flight crew was likely involved in emergency procedures associated with detection of a cargo fire (Emergency checklist for main deck fire smoke) and control of smoke. (Emergency checklist for main deck smoke evacuation)
  • Flight 295's initial report of smoke to MRU was made at about 11:49pm. Communications between Flight 295 and MRU continued for about fifteen minutes before contact was lost. These fifteen minutes of communications between Flight 295 and MRU that were recorded by MRU, along with the limited recording from the damaged CVR, provide information about crew activities in the last minutes of the flight. The flight data recorder (FDR) was not recovered from the crash site, but like the CVR was located in the vicinity of the Class B cargo compartment and would have been susceptible to the same kind of fire damage as the CVR.
  • Review of the CVR tape and the communications recorded by MRU indicate that the emergency on board developed quickly. Within four seconds of the audible smoke detection warning in the cockpit, an intercom chime can be heard on the CVR tape, possibly indicating that the flight attendants in the passenger cabin had become aware of the fire nearly simultaneously. Another intercom chime occurred about one minute later, possibly a further attempt by the flight attendants to contact the flight crew. Many of the communications with Flight 295 recorded by MRU were related to plans for an emergency landing at Plaisance Airport, but the recording also picked up some of the communications within the cockpit between crewmembers. About two minutes after the first communication with MRU regarding smoke, the pilot reported, "we've lost a lot of electrics, we haven't got anything on the aircraft now," an indication that the fire was likely affecting airplane systems. (Transcript of CVR and MRU recordings)

Probable Cause

Fire of an unknown origin had possibly: 1) incapacitated the crew; 2) caused disorientation of the crew due to thick smoke; 3) caused crew distraction; 4) weakened the aircraft structure, causing an in-flight break-up.; 5) burned through several control cables; 6) caused loss of control due to deformation of the aircraft fuselage.

References

Aviation Safety Network

FAA Lessons Learned

Revision: 20140329
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