Soon after departing Riya, the pilots of
Saudia Flight 163 get terrifying news.
Fire. Fire in the cabin. A fire in
the cabin is spread very very rapidly.
Fire equipment is in standby positions and
ready. The passengers were probably
terrified. They're able to return to the
airport. Okay, we are shutting down the
engines now and evacuating. But Only
minutes later Saudi 163d read everyone
on board is dead. None of it made any
sense. Investigators discover critical
evidence on the cockpit voice recorder.
It's just smoking the aft he continually
downplaying the situation. If he had gone
back to see for himself then
perhaps things would have been different.
It's 20 past nine on a hot evening at
Saudi Arabia's Riyadh International
Airport.
Saudia 1122 line up and hold clear
to leave Riyadh via derma. Climb and
maintain three five zero left turn from
takeoff. In the tower, controllers are
handling a full roster of flights. Most
are scheduled after sunset when the heat
dies down.
Everything is running smoothly. Riyad Saud
163 until. Until a recently departed
Saudia flight calls in. Go ahead 163
we're returning back to Riyadh which
changes everything. Clear to reverse
course back to Riyadh. Request reason
Saudia163 we've got fire in the cabin and
please alert the fire trucks. This is
extremely dangerous. It doesn't get any
more serious than this. This is basically
a pilot's worse case nightmare.
Okay, cleared back. You can descend to any
altitude you'd like. 163 we can descend to
any altitude. When an aircraft reports
to the air traffic control tower that they
have a fire on board, they clear other
airplanes out of the way and that airplane
is given top priority to land and an
evacuation should then ensue.
The flight originated in Karachi,
Pakistan. Before stopping over in Riya it
was heading to Jeddah but now must turn
back. You're number one for landing.
163.
Saudia Flight 163 is a TriStar L1011.
The L10011 is a three engine wide body
long range transport airplane. It was
designed to go very long distances, carry
hundreds of people, had excellent
performance and mechanically reliable.
There are 287 passengers on board
and some at the rear of the cabin are
having difficulty breathing. The smoke is
the first indication of a fire. The pilots
reported to air traffic control. The
passengers were probably terrified and the
aircraft needed to be on the ground as
soon as possible. 38 year old captain
Mohammad Ali Hawaia Is the pilot flying?
He's been with Saudia for 15 years and is
now responsible for getting the plane and
passengers back safely.
26 year old first officer Sami Abdullah
Hassanein is the pilot monitoring how many
passengers on board. You've got a full
load.
I would declare an emergency.
Yeah. American Bradley Curtis is
the flight engineer. You really could
not fly an airplane like the L1011 without
a flight engineer to manage all of the
aircraft systems. That modern day air
aircraft are all done by automation.
Flight 163 is now less than four minutes
from the airport. Ladies and genn please
stay in your seats.
Emergency crews are standing by.
We are at Saudia 16310 miles final Runway
and sight. Are we Cleared to land? 1063
clear to land. Wind three two zero at five
clear to land. Can you confirm you alert
of the fire trucks? Affirmative. Thank
you. Riyadh SAO163 as
the smoke in the cabin increases the
purser does her best to prepare passengers
for landing.
Place your hands behind your head. Head
with on your knees.
Saudia 163 has been on fire for at least
17 minutes.
A fire in the cabin can spread very very
rapidly.
It can be very difficult to contain. So it
becomes a race against time.
Saudia160 fire equipment is in standby
positions and ready. Please advise the
fire truckks to be at the tail of the
airplane after touchdown please. Yes we'do
30 10.
The L1011 touches down 16 minutes after
the crew first called in the fire tower.
Could you advise if there's any fire in
the tail of the aircraft? Stand by guys.
Do you see a fire in the tail? The
controller checks with the fireteam on the
ground. We don't see flames.
No, no fire they say no, nothing they can
see.
163Saudia163 now
turns onto a taxiway and
comes to a stop. Once the aircraft
comes to a full stop it theoretically
should be able to be evacuated in under 90
seconds. Saudia 1:63 do you want to
continue to the ramp or do you want to
shut down? Stand by.
Okay, we are shutting down the engines now
and evacuating. Okay.
Saudia163 understand you are holding and
shutting down? Affirmative. And
evacuating.
When you have a fire in the cabin the
available oxygen is being eaten up very
quickly. Passengers cannot breathe.
They are being overcome by smoke and fumes
and you have to get the doors open and get
people out. The planes'doors
remain closed. The fire is spreading.
There's Fire in the tail. Time to turn the
engines on. Firefighters are unable to
approach the plane with an aircraft of
this size, even with those engines at idle
speed, they can actually still suck
individuals into the engines. Captain said
he's switching off the engines and
evacuating now. Put the fire out, please.
We can't because the engines are still
running. The engines are still running. I
can hear them.
So as these toxic substances continue to
build such as carbon monoxide,
eventually you lose consciousness and you
and you die. Saudi 163,
do you read? Saudi 163,
do you read? Saudia 163,
if you reach, shut down the engines.
Goshall.
There's no response from the cockpit and
no signs of an evacuation. So none of it
made any sense. Three minutes
and 15 seconds after stopping on the
taxiway, flames consume the aircraft.
Not a single person escapes.
My heart breaks for them.
The next morning, the scale of the
devastation is clear. The fire
has obliterated the upper fuselage from
tail fin to cockpit.
All 301 people on board are dead.
It's the second deadliest single aircraft
disaster to date. It was a very
tragic situation. It was just
inconceivable to everyone. It's now
up to investigators to sift through the
smoldering wreckage to find out what
happened. Flight 163 had two main
questions to present to the investigators.
One was why the aircraft came to a stop
and didn't evacuate the passengers. And
the other was why was there a fire on this
aircraft in the first place?
The National Transportation Safety Board,
or NTSB and the aircraft manufacturer
Lockheed send investigators to Riyadh to
help the Saudis determine the cause of the
catastrophic fire on Flight 163.
The Saudis were in charge, but according
to international rules. But they didn't
have a lot of major aircraft accident and
experience. So the US NTSB supported them
and helped them with the investigation.
Just some soot. Black box should be fine.
Crew were found in their seats. But look
at where the passengers and some of the
flight attendants were found.
Investigators discover that passengers had
moved forward and gathered near the doors
after the airplane came to a stop. There
must have been mass confusion.
Did they try to open the doors? It doesn't
look like it. None of the emergency
handles were pulled.
The fact that no one attempted to open the
doors from the inside of the aircraft
leads me to believe that they were already
incapacitated and could not
open their doors. They examined the
devastated cabin to figure out how the
fire started. Looks like someone tried to
put out the fire.
The Roof was totally gone, the sides were
gone. Everything was burned away.
The seat frames with the fabrics were all
burned away.
Total destruction in the cabin area.
There's something at the back you're
goingna want to see.
Well,
what do we have here? When we got to the
back part of the airplane on the left side
in the aisle was a hole in the floor.
Looks like the fire came up through the
floor. The hole is the
investigator's first clue about the origin
of the fire.
Yeah, we need to get down there.
Appeared to me that's where the fire
started, under that hole. Because the
fire burns up, not down.
So that made us want to know what was
beneath that hole.
Be careful there. Investigators examined
the cargo compartment below the rear
cabin. Looks like the fire
burned a hole through the compartment
ceiling right here.
Fuel lines are scorched. The throttle and
flight control cables are damaged too.
On a Tristar, the control cables,
throttle cables and fuel lines run through
an 8 inch space above the rear cargo
compartment. Did a
burst fuel line caused the fire?
When investigating any fire, you're
looking for the causes that may be very
obvious. Engineering things, mechanical
things that you look at to try and see if
you can eliminate those sources of fire
and ignition.
Investigators also discover a burned out
hole on the left side of the compartment.
It's like a burst hydraulic pipe, some
melted wires, maybe an electrical short.
Don, A hydraulic leak caused the fire.
When we looked inside that cargo
compartment, there were all kinds of
possibilities of what could have caused
the fire.
They removed the charred mechanical
components for further testing.
As part of the investigation, there were
several things we wanted to eliminate at
the start, including was it electrical
failure, was it a hydraulic systems
failure or some other mechanical failure?
If there is a fault in one of the systems
on this plane, then the Tristar fleet,
nearly 200 planes flying worldwide,
could be at risk as well.
We've got the results.
Lab tests have been performed on the fuel,
electrical and hydraulic systems from
Saudia Flight 163.
No detectable evidence that the fuel
system leaked.
What about the electrical system? No,
there were no shorts and the hydraulic
systems were also fine.
The tests we conducted indicated that all
the failures that occurred with the
systems were caused by the fire. They did
not cause the fire,
so the fire must have started inside
the cargo.
We need to rule out a bomb.
A bomb expert from the UK was brought in
and his expertise is determine if
there was explosives or incendiary
devices. Nine months
earlier, the Great Mosque in Mecca was
seized by insurgents who called for the
overthrow of Saudi Arabia's rulers.
Hundreds of worshippers were killed. Did
extremists plant a bomb in the luggage
compartment of this flight headed to
Mecca? No evidence of a
timing device. No structural damage
suggesting an explosion. No small
fragments in the structure.
So no bomb.
The bomb experts an exhaustive search and
examination of the wreckage, including
wasn't electrical. His investigation
revealed no explosives, no incendiary
devices.
Let's check previous cargo fires for
patterns. Good idea.
Are there any clues from cases similar to
that of Saudia Flight 163?
We looked at previous in flight fires and
fires on airplanes and cargo compartments
to see what caused those, to see if it
would point us in a direction.
Matches. Matches. Take a look.
Last year, British officials identified
three different incidents in which matches
had started a fire in luggage being loaded
onto a plane. Hard to believe
it's even possible. We had one incident
where the luggage was thrown into the
cargo pit. It started smoking and then
caught fire. And the matches in those days
were not safety matches. Today it will not
ignite unless it's on a special fabric.
You ready? Investigators test how easily
matches could ignite.
Hit it with something hard and poof, it
would catch fire. That was the non safety
matches. It surprised us that the matches
could catch fire so easily. So it was a
serious hazard.
The theory that matches were the source of
the fire seemed possible. Passengers on
this particular flight were likely to pack
them in their luggage. Many of
the passengers on the airplane were
pilgrims heading to Mecca and they would
have had stoves with them to cook when
they were camping out. They would have had
matches to start the stoves.
Matches seemed like the most likely cause.
Mm hmm. We didn't find any
evidence of matches causing the fire, but
obviously that evidence would have been
destroyed. But it was a pretty good hunch
on our part. But if some
luggage actually caught fire, would it be
enough to bring down a sophisticated
jetliner? Fire in a cargo compartment
isn't supposed to be able to spread. The
compartment should have sealed off and
starved the fire of any oxygen.
Maybe the compartment'fire suppression
system failed.
Unlike the airtight cargo holds at the
front of the airplane, which were designed
to hold cargo containers, the aft hold was
designed for passengers, baggage, and any
pets they were traveling with.
The aft cargo compartment was different
than all of the other cargo compartments
on this aircraft because it was designed
to be able to hold live animals. So it was
pressurized and it had a source of fresh
air.
An inlet fan and three valves allow for
airflow. But if smoke sets off one or
both detectors, the fan stops and the
valves close, sealing the compartment and
cutting off the supply of oxygen.
In the case of Flight 163,
obviously something in that self
extinguishing system did not take place
and the fire continued.
Okay, see if they work.
Investigators test both of the cargo
compartment smoke detectors to determine
if they'functioning properly.
Okay, that one's working. What about the
other one?
Smoke detectors were working. There must
be another reason why oxygen continued to
fuel the fire. Maybe there was something
wrong with the compartment itself. Good
point. Let's find out.
Smoke detectors were working correctly,
but the fire spread even though it was
supposed to have been self extinguished.
And we needed to find out why.
Let me check the specs.
Investigators examine the specification of
the rear cargo compartment onard Saudia
Flight 163 to better understand how it's
designed to contain a fire. According to
this, it is considered a class D cargo
compartment.
Designation states that a class domartment
is 500 cubic feet.
The size of the L1011 compartment.
The L1011's cargo compartment is 700
cubic feet. The cargo compartment
on the L1011 is 200 cubic feet bigger than
its original design. We determined
that the original certification of a class
D cargo compartment was based on smaller
airplanes. Over the three decades since
1950, the aircraft design changed.
It grew in size, including the class D
cargo compartments. If the compartment
was larger, that means there's more
oxygen. Maybe that
fueled the fire instead of extinguishing
it. It appears that the bigger
the aircraft got, the bigger compartments
got. There was no modification of the self
extinguishment of the compartments.
Investigators recreate a cargo compartment
that matches the specifications of Saudia
163's aft cargo bay. To test its ability
to self extinguish.
Matches and an igniter are placed inside
the compartment to start the fire from a
safe distance.
Okay, let's see what happens.
Let's see if the fire extinguishes.
It's progressing quickly.
As investigators expected, the fire does
not burn out. A small fire that
in a normal class domartment would
extinguish and burn all its oxygen up.
In a large compartment, it wouldn't do
that. It had too much oxygen. It's burning
through the fire resistant liner.
The L10011 construction of the cargo
compartment included the use of a Nomex
liner that's used for fire suits. And it
was thought that that would protect the
compartment and allow for this self
extinguishment.
Instead of burning out, it burned through
the liner in 2 minutes and 59
seconds.
That explains why the fire wasn't
contained well. We were quite surprised
by the findings of our test of the Nomex.
It failed miserably and permit the fire to
spread much quicker than we had suspected.
The extra oxygen in the larger compartment
fuels the fire intensely and long enough
to penetrate the Nomex liner, progressing
into the side wal ceiling and damaging the
plane's components. At the same time,
smoke escapes the cargo compartment and
seeps through the air vents into the
cabin. Eventually, flames penetrate the
cabin floor.
Why the pilots didn't stop and shut the
engines down sooner, which would have
prevented the fire from spreading
throughout the plane, now remain Saudi
163's biggest mystery. Why there was not
an immediate stop and an attempt to
evacuate the passengers. All these things
make no sense.
What was your first indication that there
was a problem?
Investigators turned to the air traffic
controller for further details. Twelve
minutes into the flight, the crew reported
a fire in the cabin and asked to turn
back. Riyadh Saud 163,
go ahead. 163. We're turning back to
Riyadh. Clear to reverse course back to
Riyadh. Request reason Saudi
163. We've got fire in the cabin and
please alert the fire trucks then.
The approach back was normal. So was the
landing. How did they sound? The
communications seemed normal even after
they stopped on the taxiway. Saudia 1 63,
do you want to continue to the ramp or do
you want to shut down?
Stand by. Okay, we are shutting down the
engines now and evacuating. And you
couldn't see the fire? Not until after
they had stopped. The plane just sat there
with the engines running for another three
minutes. When they finally shut them down,
I guess it was too late.
It's still not clear why the engines were
not shut down sooner or why
the plane wasn't stopped on the Runway
right after touchdown. The Kevtain's
decision not to stop the aircraft
immediately after landing and evacuate was
reckless and irresponsible. In my mind.
It is imperative that you get the
passengers out as quickly as possible.
While investigators will never know why
the engines weren't shut down in time,
could something have prevented the pilots
from stopping the plane earlier on the
Runway? Nothing unusual.
Here they scrutinize the recorded flight
data. Looks like a normal flight. Do we
have the data on the braking system?
Maybe the brakes failed. Here it
is. Did the brake hydraulics fail,
preventing the pilots from stopping the
plane? See for yourself.
Our examination of the airplane revealed
that the braking system was working fine
and the pilot could have easily Stopped
the airplane on the Runway. It'as if the
crew was flying a plane that wasn't even
on fire.
Why did they allow the aircraft to roll to
the end of the Runway and then to taxi
onto a taxiway and then take over three
minutes to shut the engines down? All of
these behaviors are not consistent with
how most crews, if not all crews, would
handle an emergency like that.
We need to find out what went on in that
cockp. I'll check on the progress of the
CBR download.
The investigation now hinges on the
cockpit voice recorder or cvr. Can it
explain why the pilots treated the landing
like a normal flight instead of an
emergency?
You review the recordings? Oh yeah. You
need to hear this for yourself.
Investigators listened to how the crew of
Saudia Flight 163 dealt with the onboard
fire. Let's start from when the smoke
alarms go off seven minutes into takeoff.
Vif cargo smoke
detection be afghard off now
would's a that's both of them.
Hold on. The alarms go off long before
they report a fire.
They got two smoke warnings and then there
was a five minute on 30 second delay
before they turned around. By the way,
we have smoking there. The captain sounds
skeptical. I would say so, yeah.
What's the procedure for it in the
checklist?
There isn't anything about it. The
abnormal procedures. Huh?
Nothing about it. Pause the recording.
They waste time going through the smoke
alarm procedures before deciding to turn
around. And on top of that they're looking
in the wrong place. They should be looking
in the emergency section. There was
obvious confusion between checklists. The
emergency checklist need to be immediate
action and the abnormal checklists are
actions that you take to avoid getting
into some sort of an emergency condition.
There's a lack of urgency here.
Shall I go back there and see if I can
smell something? Okay,
sure. Okay. If I
can see or smell anything, I think we
better go back. Okay, sure.
40 seconds later.
Yeah. We gott fire back there. We do.
Yeah, we do.
It's okay. S sel control, we're heading
back. The captain is surprised to learn
there's a fire. Only then does he turn the
plane back to Riyad. It's been five and a
half minutes since the first alarm. I
would declare an emergency.
Yeah. Clear to reverse course back to
Riyadh. Request reason declare
emergency.
Fire. Fire in the cabin.
The engineer has already told him there's
a fire. And his purser has corrorated
that.
Captain doesn't declare an emergency and
it happens again. Queue it up to 2250.
15 minutes. Into the flight.
Did we declare an emergency?
Negative. Okay. The fire trucks
will be waiting for us though. Yes.
The captain is ignoring his crew. In the
1980s, the captain was God on the
airplane. There was never any discussion
about including any other crew members in
his decision making process. And arrogance
and hubris may very well have played a
large role in this. It gets even
more disturbing. And the captain is asked
about evacuating playist elections.
Shall we evacuate?
It's the purser in the cockpit again. Can
we evacuate all the passengers? Flaps 10,
please. The captain ignores the purser's
question. When we're on the ground.
Yes. Flubend.
The captain was asked a total of seven
times if an evacuation
was going to happen. And each time he
ignored the request. There were two other
people in the cockpit. What were they
doing? First officer? Not much.
I would declare an emergency.
Yeah. Clear to reverse course back to
Riyadh. Request reason. Declare emergency.
He never once challenged the captain s
stubbornness. The first officer was
silent and passive. The captain
just left the first officer completely out
of the picture and continued to fly.
What about the flight engineer?
Reviewing the transcripts, investigators
discover a troubling patent. If anything,
he made the situation worse. How so? By
repeatedly downplaying the situation,
Continually saying things like no problem.
Less than a minute after the flight
engineer reports fire in the cabin, the
captain asks him to do another check.
This time heassment it's
just smokeing the aft.
Okay, we're going back to Rio. Okay.
No problem.
Everybody's panning in the back though.
No problem. No problem.
No problem at all. Downplaying the
severity of the situation can
most certainly affect the captain's
perception of what exactly is going on.
What happens on the ground W It's hard to
know. Play from the 500 foot alert.
500 and 500 hydraulic.
You've got low pressure on number two.
Looking good. Tell them to not evacuate.
Place your head behind your head. Head
between your knees. No need for that.
We're okay. No problems.
No problem.
Minimums. Minimums.
100. 100. 100.
50. 50. 40.
30. 30.
The fire is so severe at this point that
it burns through the CVR's electrical just
before touchdown. The fire destroys the
wiring that powers the cockpit voice
recorder. It's a setback for the
investigation. We have no idea of the
chotic nature of what was going on in
the cockpit at that time. He wasted
five minutes deciding to turn around. He
wouldn't declare an emergency even though
he's been told there's a fire in the
cabin. He failed to evacuate everybody on
that plane. And the other pilots did
nothing to change his thinking.
What kind of emergency training did this
crew have? Let's pull their files and see
investigators examine the pilot records of
Saudia 163's crew members to determine if
they were properly trained to deal with a
fire. Hmm. This does not
look good. The first officers was dropped
from pilot training but reinstated two
years later as a result of committee
action. Committee action? I have a
different term for committee action. Its
friends or family. He wanted to be a
pilot. He was going to be a pilot and
someone helped him become a pilot.
It's nothing compared to the flight
engineer. Listen to this. Failed to
qualify as a captain and first officer was
only hired by the airline as a flight
engineer after paying for his own
training. The flight engineer was also
another incompetent person. He flunked
previous training and he paid for it out
of his pocket to become certified as a
flight engineer. The captain's training
history is no better. The records show
that the captain's qualifications were
also questionable. Slow to learn,
Needed more training than normally
required. Difficulty varying from a set
pattern. The captain's training record
indicated that he was indecisive and slow.
And that was all reflected in the events
of this accident. All three of these guys
were extremely weak.
None of them should have been in the
cockpit and certainly not three
of them together. It was literally a crew
pairing of an accident waiting to happen.
If anything unusual was going to occur
these people were going to descend into
some state of confusion. Which is exactly
what happened.
Because the cockpit voice recorder failed
just before the Tristar landed. The
investigation was unable to determine why
the captain didn't order an evacuation.
But they did point to his actions as
contributing factors.
It is possible that the captain was in
denial about the severity of the fire and
the situation in the cabin. But if
he had gone back to see for himself then
perhaps things would have been different.
The other thing to consider is that air
crews realize that if they shut an
airplane down on a Runway that
that effectively closes the airport.
These are things that could put your job
in jeopardy. So who really knows what his
logic was? But what is certainly clear
was this captain was definitely not in
command of this emergency.
Even though investigators are unable to
confirm that matches with a source of the
fire, they do recommend improvements for
all cargo compartments.
To make the cargo compartment safe you had
to put a fire extinguisher in there.
Detectors and extinguishers. And that's
what we recommended. They do. They also
recommend removing the Nomex liner.
The investigation went back to the
manufacturer. They identified a way to
improve the resistance of the compartment,
to replace the Nomex and return the
compartment to a full idea
of self extinguishment.
The Federal aviation Administration, or
FAA, considers the recommendations. But
it's not until 1998, almost two decades
later, that the FAA changes the
regulation. Now all cargo compartments on
commercial airliners must contain both
fire detection and fire suppression
systems. In the aftermath of the tragedy,
Saudia asks Bob McIntosh to revamp its
safety training and procedures. I was
hired to form a corporate safety
department, and it was my pleasure to do
that for my six years there.
There were numerous lessons that we
learned from how cargo compartments are
designed and much better designed. Flame
retardant materials are now used
throughout the cabin, but our aviation
system is safer because of this accident.
All those things are wonderful takeaways
from a very, very tragic situation.