Abstract
Among the remarkable flight accidents, Saudia Flight 163 case holds a special place, both due to the death toll and due to the fact that it did not involve a crash at all. The disaster that took away lives of all passengers and crew members at the turn of 1980s was thoroughly investigated and recognized as the second deadliest aircraft accident (at that time) after Ermenonville air disaster involving Turkish Airlines flight 891 (Witkin, 1981). While the deadly incident happened after the safe emergency landing of the plane, the main reason of Flight 163 tragedy is human factor. The present report paper is aimed at investigation of the flight and disaster details with further discussion of the human factor as the major reason for such a deadly outcome.
Saudia Flight 163: Overview
Saudia Flight 163 is referred to a scheduled passenger flight originating in Karachi, Pakistan. On its flight to Jeddah, the plane made an intermediate landing in Riyadh International Airport, Saudi Arabia, on Tuesday, August 19, 1980 about 18:08 GMT. The flight involved the Lockheed L-1011-200 TriStar aircraft registered HZ-AHK with 287 passengers and 14 crew members on board (Lewis, 2014). Around seven minutes after the plane owned by Saudi Arabia Airlines took off from the Riyadh airport, the uncontrolled fire was detected in the C-3 cargo compartment of the plane; while the crew was forced to make an emergency landing back in Riyadh. The plane “landed at about 18:36 and then taxied clear of the runway and came to a stop on an adjacent taxiway» (The Presidency of Civil Aviation, 1982, p.1); however, having been parked on the taxiway, the plane was destroyed by fire before the airport emergency personnel could open the door to evacuate all passengers.
The Lockheed L-1011 was flown by the crew the Captain Mohammed Ali Khowyter (38 years, Saudi national), co-pilot Sami Abdullah M. Hasanai (26 years, Saudi national) and the flight engineer Bradley Curtis (42 years, USA national), all being experienced professionals. The number of passengers on board reached 287: although the majority was comprised by Pakistani religious pilgrims and Saudis, there were also two Americans, one Finn, four Koreans, one Dutchman, one Japanese, two Thais, three Britons, one Irishman. Moreover, 15 passengers of the flight were infants.
Seven minutes after the plane took off, the crew members received warnings about smoke detection in the aft cargo compartment. Moreover, flight attendants reported about smoke detection in the rear passenger cabin. Therefore, the next four minutes of the fight were spent by the crew in attempts to confirm the warnings, with the flight engineer going to the passenger cabin to check it for smoke. Once the flight engineer confirmed the warning about smoke emanating from the rear area of the passenger cabin, the Captain decided to make an emergency landing back in the Riyadh Airport and informed Riyadh Terminal Area Control Center. Having received the Control Center’s permission, the Captain turned off the engine no.2 and took back course. Meanwhile the fire in the cargo compartment was spreading rather fast. The Captain asked the communicator to prepare airport emergency crews for evacuation and fire-fighting operations (Aviation Safety Network, 2004). During the back flight, the flight attendants of Flight 163 attempted to fight the fire, which had already reached the cabin floor, with available fire extinguishers.
After approximately 20 minutes, the aircraft landed in Riyadh; yet, it taxied off to the taxiway instead of making an emergency stop right on the runway. The airport emergency crews asked the cockpit crew to shut down the engines for them to access the plane door and begin evacuation of the passengers, but the engines were shut down only several minutes after the plane stopped. At the same time, the last transmission received from the crew stated that they were about to begin evacuation of the plane passengers. However, the door was not opened after the message. Eventually, all passengers and crew members were incapacitated by fire and smoke inside the plane and all of them died of smoke inhalation or burns. Moreover, the airport emergency crew managed to open the plane door only after 23 minutes after landing: as the fire erupted and engulfed the entire aircraft, the latter burned down, with only wings and the vertical stabilizer left intact.
Human Factor
The report based on the investigation of the Presidency of Civil Aviation (1982) in Jeddah concluded that the initial cause of the plane accident was ignition of the fire in the C-3 aft cargo compartment; yet, the much attention in the report as well as in all further discussions of the case was paid to the human factor as a significant contributor to the tragedy. This contribution is amplified by the fact that there was no plane crash, instead, the plane landed safely in the airport of departure and even reached the taxiway. However, both prior and further actions of the crew and the airport emergency services eventually led to death of all people in the plane.
First of all, much attention in investigations of human factor reasons has been granted to the plane cockpit crew, their actions and competency: “The Three Saudi Arabian Airlines pilots involved failed to take crucial actions in a timely way” (Wise et al., 2009, p.5-11). After receiving the fire warning, the cockpit crew showed inaction and casualness, spending too much time on deciding on their actions to eliminate the threat. The men spent around four minutes trying to find the procedure of dealing with this kind of emergencies in the instructions, which is often attributed to their insufficient English skills as well.
Some authors including Thomson (2015) attribute the outcomes of the accident to incompetency of the cockpit crew members. Both the Captain of Flight 163 and the co-pilot had rather controversial training records with reportedly ‘slow’ learning skills or poor performance. According to the official accident report, Captain Mohammed Ali Khowyter was a slow learner, had problems in recurrent training, needed more training as it is normally required and showed little success in upgrading to newer aircraft (Thomson, 2015, p.178). The co-pilot, Sami Abdullah M. Hasanai, is reported to have qualified on the discussed type of plane, Lockheed TriStar, only eleven days before the tragedy, which means that his experience with this aircraft might have been insufficient in managing emergencies. Bradley Curtis had even poorer record in Saudia Airlines: he was removed from the position of pilot due to unsatisfactory performance and later retrained for the position of Flight Engineer to work on Lockheed TriStars. Moreover, both the official report and other sources state that Curtis might have suffered from dyslexia, which could serve an explanation for difficulties in locating the needed emergency procedure instruction (Thomson, 2015, p.179). This fact is supported by the record from the wreckage site, where the Captain calls the Flight Engineer “a jackass and states that the needed emergency procedure should be looked for in another place of the instruction.
Another notable thing illustrated by the flight crew record is the fact that the Captain seemed to be flying the aircraft himself. However, it is suggested that the right way to act in this situation would have been to assign Hasanai piloting of the plane and focus on managing the crisis (The Presidency of Civil Aviation, 1982, p.70). However, the fact that the co-pilot had been working only eleven days on Lockheed TriStar is a quite plausible reason of why the Captain did not ask Hasanai to pilot on his own. At the same time, the Captain was apparently confused by the information provided by the Flight Engineer concerning the scale of the threat: after returning from the cabin, Curtis confirmed that smoke and hence fire were indeed detected (for the instructions of the Saudi Airlines require re-checking of the automatic warnings), but he continued to underestimate the threat and stated that there was ‘no problem’. Although Curtis might have hope that everything would end well, he should not have underestimated the serious threat confusing the Captain and his actions.
One more crucial mistake made by the crew of the Flight 163, which is mentioned by Thomson (2015, p.182) is the overlooking the need to make oxygen masks available for passengers. Neither passenger oxygen system not flight station oxygen system was utilized during the crisis which might have contributed to smoke inhalation by the passengers. Focusing in piloting the plane back to the airport, the crew neglected the passengers’ safety and preparations for immediate evacuation after landing. Even more, taxying the Lockheed to the taxiway took two extra minutes that could have been used for immediate evacuation if the plain had made an emergency stop on the runway right after landing: “The Presidency believes that these two minutes were significant with respect to survivability» (The Presidency of Civil Aviation, 1982, p.71). Therefore, underestimation of the serious fire threat by the Captain and his decision to ‘waste’ two more minutes for taxying the aircraft off the runway were significant contributors to eventual mortality. In addition, none of the flight attendants used the emergency R-2 door handle after the plane stopped, though the investigation showed more than one flight attendant to have been near this door. With the reasons for this being debated, one assumption states that the cabin crew were possible incapacitated by the smoke at the time of landing.
Human factor in Saudia Flight 163 case is manifested in actions of the airport emergency services as well. The latter were reported to have insufficient English skills to make sense of the emergency door opening instruction for the Lockheed TriStar and open the main cabin door to evacuate the passengers. In addition, it has been stated that Riyadh airport emergency services, just like the cockpit crew, were not prepared for such emergencies and thus could not manage the crisis promptly.
Conclusion
In the recent years, the tendency to investigate accidents for human factor causes has become similar to the effort to assign blame. However, investigation of such cases as Saudia Flight 163 not just shows who is to blame (especially as the crew perished in the accident, too), but also indicates dangerous gaps in training and crisis management skills. In fact, the case of Saudi Flight 163 is especially illustrative in terms of human factor causes, for the tragic death of 301 people was not caused by the crash or mechanical impacts: negligence, wasted time, failure to take appropriate timely actions and gaps in training/management killed 301 people just after the safe landing on August 19, 1980, and these errors are to be minded by the aircraft training services.
Reference list
Aviation Safety Network (2004). Saudia Flight 163 - 19 AUG 1980 [Transcript]. Retrieved April 17, 2016 from https://aviation-safety.net/investigation/cvr/transcripts/cvr_sv163.php
Lewis, J. (2014). Worst Plane Crashes In History. Masterlab.
Presidency of Civil Aviation (1982). Aircraft Accident Report: Saudi Arabian Airlines Lockheed L-1011, HZ -AHK Riyadh, Saudi Arabia August 19th 1980. Retrieved April 17, 2016 from http://www.webcitation.org/6MHvXXVfh
Thomson, J. R. (2015). High Integrity Systems and Safety Management in Hazardous Industries. Butterworth-Heinemann.
Wise, J. A. Hopkin, V. D., & Garland, D. J. (2009). Handbook of Aviation Human Factors, Second Edition. CRC Press.
Witkin, R. (1981). Safety board urges improvements in fireproofing of jumbo jet bays. New York Times (February 11, 1981). Retrieved April 17, 2016 from http://www.nytimes.com/1981/02/11/us/safety-board-urges-improvements-in-fireproofing-of-jumbo-jet-bays.html
