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The aeroplane fire in Manchester August 22,  1985 – KAMEDO-report 58

The Kamedo-reports are published by the Swedish Disaster Medicine Study Organisation (Kamedo), at the National Board of Health and Welfare. Observers study the medical, psychological, organisational and social aspects of disasters. The results, with a focus on experiences gained, are presented in the reports.

This report is entirely in Swedish. Only summary in English.

Summary

On the morning of 22 August 1985 a Boeing 737-236, carrying 131 passengers and 6 crew on a charter flight to Corfu, began its take-off to Manchester International Airport. As the airspeed passed 125 knots on the runway, an explosion in the left engine ignited fuel leaking from the penetrated left wing tank. The commander abandoned the take-off immediately and brought the aircraft to a halt finally turning off the main runway to the right. Hereby, a wind of 7 knots carried the carried the fire onto and around the rear fuselage. Subsequently, fire developed within the cabin. In a few minutes the aircraft was destroyed and 54 persons on board were rapidly killed, most of them by the effects of toxic combustion gases.
Previous international reports have described similar aircraft fires with great variation in numbers of fatal outcome. The Swedish Organizing Committee for Disaster Medicine for Disaster (KAMEDO) regarded the Manchester accident as a potential "model accidents" for an aircraft fire. In order to obtain further information of events such as the fire fighting, the evacuation and rescue work and the medical sequelae for all the victims, KAMEDO sent two investigators to England in October 1985. Through kind co-operation from the Air Accidents Investigation Branch (AAIB) in Farnborough, Manchester International Airport, and the Manchester hospitals in charge, it became possible to reach a more overall impression of the disaster.
However, the present report had to await the official accident report from the AAIB, which was published first in 1989. This delay partly due to the scientific examination of the survivability issues from the AAIB and also the extensive legal inquest which followed the Manchester accident. This KAMEDO report is, however, not merely a reflection of that of the AAIB, but also founded on interviews with fire service personnel, police authority and hospital staff in Manchester. Interviews with the survivors were not allowed since British law prevents foreign doctors from practising medicine in England.
The main aim of this report is to collect information of value for future emergency response planning. The Manchester experience can be summarized in e following six problem issues:
1. Problems in communication/information The decision to turn the aircraft from the runway to the right had a critical effect on the fire. This might have been avoided if ATC had reminded the commander of the wind direction when confirming the fire.
In the course of events, there were communication; between cabin crew and passengers, between different fire service personnel, airport police, ambulance drivers etc. Lack of medical information to survivors and disinterest in psychological follow-up may also be regarded as a problem of communication with possible harmful consequences in a future perspective.
2. Panic reactions Panic-like reactions occurred already at an early stage of the fire, before the aircraft came to a halt, especially among the passengers who were trapped in the back of the cabin. This made evacuation even more difficult in this accident.
3. Problems of evacuation Apart from panic reactions and the temporary jamming of the right forward exit, two fundamental problems of evacuation arised: the heavy, blackening toxic smoke and the diagonal cutting-off of the emergency exit of the aircraft. The combination of these two factors explains why so many passengers were killed in the Manchester accident.
AAIB recommends therefore that the existing regulations of the Evacuation Certification of public transport aircraft should be changed to test evacuation time "using hall the total number of exits, disposed toward one end of the cabin; that end being chosen which represents the greatest restriction to passenger egress". The test should also simulate "a defined dense smoke atmosphere within the cabin, existent from the initiation of the evacuation until its completion".
4. Effects of smoke and toxic gases Pathological examination showed that 48 passengers died on board the aircraft as a result of smoke/toxic gas inhalation, i.e. hydrogen cyanide and carbon monoxide. Only 6 passengers died from direct thermal assault. Most survivors from the middle or near cabin seats were incapacitated extremely difficult. The irritant toxic gases affected simultaneously visual respiratory and cerebral functions.
It is a fact that passenger smokehood protection has a major effect against smoke and toxic/irritant gas incapacitation in aircraft fires. In Manchester accident, there is little doubt that survivability would have been greatly improved by donning passenger smokehoods at the proper time. The AAIB report reviews in detail the case for passenger smokehood protection, ending with a recommendation to the Civil Aviation Authority (CAA) to "urgently give consideration to the formulation of a requirement for the provision of smokehoods/masks to afford passengers an effective level of protection" during toxic aircraft cabin fires.
5. Change of policy in medical care/disaster emergency response plans At hospital, the survivors suffered mostly from the effects of toxic smoke, i.e. irritation/inflammation in eyes and air-passengers. Burns and traumatic injuries of importance were uncommon. A majority of the survivors also showed signs of psychic shock. Several persons had the experience of family bereavement or the like, which obviously should have necessitated crisis intervention.
Medical rescue and care have to be planned accordingly. There should be no unnecessary treatment and delay at the site of the accident. Instead, safe and fast evacuation/transportation should be accomplished to hospital with specialist facilities, such as intensive respiratory care, toxicological unit crisis intervention teams etc. This is fundamental for the professional handling of this type of accidents.
In the Manchester accident, the two Hospitals involved showed high standards of somatic care, but the immediate psychological support seemed to be almost none. Negligible interest was also shown in psychological/psychiatric follow-up of the victims and their near relatives.
6. Problems of convergency The phenomenon of convergency, i.e. accumulation in the rescue area of helpers, media-people, onlookers, means of transportation, etc is often recognized as a severe obstacle for effective rescue work after a disaster. Also in the Manchester accident, convergency was experienced as a problem of surprising magnitude both at the airport and at one of the hospitals. In particular, press people were described as ruthless violators of regulations.
The organizational problems of convergency should also be taken into account in the making of emergency response plans.

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