Edit Accident: L101, vicinity Riyadh Saudi Arabia, 1980 (AW HF FIRE)

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When:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Event Type:	AGC AI AW BS CFIT CS FIRE GND HF LB LOC LOS RE RI WAKE WX
Day/Night:	None Not Recorded Day Night
Flight Conditions:	None Not Recorded VMC IMC On Ground - Low Visibility On Ground - Normal Visibility
One sentence description:	On 19 August 1980, a Lockheed L1011 operated by Saudi Arabian Airlines took off from Riyadh, Saudi Arabia - seven minutes later an aural warning indicated a smoke in the aft cargo compartment. Despite the successful landing all 301 persons on board perished due toxic fumes inhalation and uncontrolled fire.
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Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

Aircraft: Operator: Type of Flight: None Not Recorded Private Public Transport (Passenger) Public Transport (Cargo) Public Transport (Non Revenue) Military/State Aerial Work Out of Service Flight Origin: Intended Destination: Actual Destination: Take-off Commenced: None Yes No Flight Airborne: None Yes No Flight Completed: None Yes No Phase of Flight: None Parked Standing Pushback/towing Taxi Take Off Climb Cruise Descent Missed Approach Landing Manoeuvring

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Origin: Destination:

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Airport: In Vicinity of airport:

Airport: In Vicinity of airport:

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Coordinates: Location: ICAO Region: AFIAPACCARSAMEURMIDNAMNAT ICAO Territory: AGANAYBGBIBKCCTDADBDFDGDIDNDRDTDXEBEDEEEFEGEHEIEKELENEPESEVEYFAFBFCFDFEFGFHFIFJFKFLFMFNFOFPFQFSFTFVFWFXFYFZGAGBGCGEGFGGGLGMGOGQGSGUGVHAHBHCHDHEHFHHHKHLHRHSHTHUKLALBLCLDLELFLGLHLILJLKLLLMLOLPLQLRLSLTLULWLXLYLZMBMDMGMHMKMMMNMPMRMSMTMUMWMYMZNCNFNGNINLNSNTNVNWNZOAOBOEOIOJOKOLOMOOOPOROSOTOYPAPGPHPJPKPLPMPOPPPTPWRCRJRKRORPSASBSCSESFSGSKSLSMSOSPSUSVSYTATBTDTFTGTITJTKTLTNTQTRTTTUTVTXUAUBUDUEUGUHUIUKULUMUNURUSUTUUUWVAVBVCVDVEVGVHVIVLVMVNVOVQVRVTVVVYWAWBWIWMWPWRWSYYPZZKZM

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Tags: ATC Training Flight Crew Training Military use of civil airport Civil use of military airport Approach not stabilised Aircraft-aircraft collision Aircraft-aircraft near miss Extra flight crew (no training) Safety pilot present Non Precision Approach Circling Approach Event reporting non compliant Inadequate Airworthiness Procedures Inadequate Aircraft Operator Procedures Inadequate ATC Procedures Airspace Design Airport Layout Ineffective Regulatory Oversight Root Cause Not Determined Military Fast Jet Formation Foreign Military Aircraft Approach to Wrong Airport Inadequate Airport Procedures Landing Flare Difficulty

Tags: ATC Training Flight Crew Training Military use of civil airport Civil use of military airport Approach not stabilised Aircraft-aircraft collision Aircraft-aircraft near miss Extra flight crew (no training) Safety pilot present Non Precision Approach Circling Approach Event reporting non compliant Inadequate Airworthiness Procedures Inadequate Aircraft Operator Procedures Inadequate ATC Procedures Airspace Design Airport Layout Ineffective Regulatory Oversight Root Cause Not Determined Military Fast Jet Formation Foreign Military Aircraft Approach to Wrong Airport Inadequate Airport Procedures Landing Flare Difficulty

Add AGC Tags

Tags: Call Sign Confusion Loss of Comms Incorrect Readback missed Phraseology Language Clarity Low Fuel Status CPDLC Flight Crew Oxygen Mask Use Take off without clearance Landing without clearance Military Formation Clearance Military/Civil Coordination Provision of Aircraft Performance Data ATC Clearance Cancelled

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Tags: CA Incursion DA Incursion PA Incursion TSA Incursion GPS VFR Navigation ATC Complicit Aircraft not in contact with Airspace ATC

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Tags: Large Birds Flocking Birds Significant Airframe Damage Flight Crew Injury Engine damage Coastal Location Migration Engine Ingestion Prior verbal warning

Add CFIT Tags

Tags: Into water Into terrain Into obstruction No Visual Reference Lateral Navigation Error Vertical navigation error Pressure altimeter setting error VFR flight plan IFR flight plan

Add FIRE Tags

Tags: Post Crash Fire Non-Fire Fumes Dangerous Goods Fire-Cabin Baggage origin Fire-Cargo origin Fire-Electrical origin Fire-Fuel origin Fire-Power Plant origin Fire-Underfloor origin Fire-Galley Fire-Wing De-Ice fluid contamination Electrical fumes - No fire Landing Gear Overheat

Tags: Post Crash Fire Non-Fire Fumes Dangerous Goods Fire-Cabin Baggage origin Fire-Cargo origin Fire-Electrical origin Fire-Fuel origin Fire-Power Plant origin Fire-Underfloor origin Fire-Galley Fire-Wing De-Ice fluid contamination Electrical fumes - No fire Landing Gear Overheat

Add HF Tags

Tags: Aircraft acceptance ATC clearance error ATC Unit Co-ordination Authority Gradient Data use error Distraction Ergonomics Fatigue Flight / Cabin Crew Co-operation Flight Crew / Ground Crew Co-operation Flight Crew Incapacitation Flight Crew Visual Inspection Food Poisoning Gross Data Error not recognised Inappropriate ATC Communication Inappropriate crew response - skills deficiency Inappropriate crew response (automatics) Inappropriate crew response (technical fault) Ineffective Monitoring Maintenance Visual Inspection Manual Handling Pilot Medical Fitness Plan Continuation Bias Procedural non compliance Spatial Disorientation Stress Violation

Tags: Aircraft acceptance ATC clearance error ATC Unit Co-ordination Authority Gradient Data use error Distraction Ergonomics Fatigue Flight / Cabin Crew Co-operation Flight Crew / Ground Crew Co-operation Flight Crew Incapacitation Flight Crew Visual Inspection Food Poisoning Gross Data Error not recognised Inappropriate ATC Communication Inappropriate crew response - skills deficiency Inappropriate crew response (automatics) Inappropriate crew response (technical fault) Ineffective Monitoring Maintenance Visual Inspection Manual Handling Pilot Medical Fitness Plan Continuation Bias Procedural non compliance Spatial Disorientation Stress Violation

Add GND Tags

Tags: Taxiway collision On gate collision Aircraft / Aircraft conflict Aircraft / Person conflict Aircraft / Vehicle conflict Aircraft / Object or Structure conflict ATC clearance error Ground de/anti icing Jet Blast / Prop wash Surface Friction Towed aircraft involved Aircraft Push Back Incorrect Parking Position Airbridge Positioning Both objects moving Wingtip clearance Centreline obscured Accepted ATC clearance not followed Surface Lighting control Hold Loading Passenger Loading Cargo Loading Fuel Loading Dangerous Goods Engine Ground Running Engine Powered Systems Test No Flight Crew on Board

Add LB Tags

Tags: Accepted ATC Clearance not followed SID bust Clearance readback error undetected TCAS RA response Manual flight Pressure altimeter setting error

Add LOC Tags

Tags: Airframe Structural Failure Significant Systems or Systems Control Failure Degraded flight instrument display Uncommanded AP disconnect AP Status Awareness Non-normal FBW flight control status Loss of Engine Power Crew Incapacitation Flight Management Error Flight Control Error Environmental Factors Bird or Animal Strike Aircraft Loading Malicious Interference Temporary Control Loss Extreme Bank Extreme Pitch Last Minute Collision Avoidance Hard landing Take off Trim Setting Incorrect Thrust Computed Unintended transitory terrain contact Collision Damage Incorrect Aircraft Configuration Aerodynamic Stall

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Tags: TCAS RA Mis Flown Accepted ATC Clearance not followed See and Avoid Ineffective Required Separation not maintained Released to Own Separation Level Bust Lateral Navigation Error ATC Error Near Miss Lateral Offset in use Mid-Air Collision Uncommanded AP disconnect Military Aircraft involved Apparent de-selection of transponder Transponder non selection

Add RI Tags

Tags: ATC error Accepted ATC Clearance not followed Incursion pre Take off Incursion after Landing Runway Crossing Intersecting Runways Intersecting extended centrelines Towed aircraft involved Near Miss Ground Collision Phraseology Intentional Premature Rotation Vehicle Incursion

Add RE Tags

Tags: Overrun on Take Off Overrun on Landing Directional Control Undershoot on Landing Wrong Runway Excessive Airspeed RTO decision after V1 High Speed RTO (V above 80 but not above V1) Unable to rotate at VR Frozen Deposits Collision Avoidance Action Parallel Approach Operations Excess Water Depth Late Touchdown Significant Tailwind Component Significant Crosswind Component Thrust Reversers not fitted Landing Performance Assessment Off side of Runway Misalignment on runway Taxiway Take Off/Landing Runway Length Temporarily Reduced Intentional Premature Rotation Incorrect Aircraft Configuration Reduced Thrust Take Off

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Tags: ICAO Standard Wake Separation prevailed ICAO Standard Wake Separation not met Accepted ATC clearance not followed Own separation In trail event Cross track event Pilot over compensation Intersection take off Intersecting extended centrelines Intersecting runways

Add WX Tags

Tags: In Flight Airframe Icing In Flight Icing - Piston Engine In Flight Icing - Turbine Engine CAT encounter En route In-cloud air turbulence Hail damage Volcanic Ash Effects Sand/Dust limited IFV Fog In Cloud on Visual Clearance Precipitation-limited IFV Strong Surface Winds Mountain Waves Lightning Damage Low Level Windshear

Add EPR Tags

Tags: Emergency Descent Emergency Evacuation Airport Emergency Medical Response MAYDAY declaration PAN declaration “Emergency” declaration Slide Malfunction RFFS Procedures Evacuation difficulties in Water Delay in Declaration of Emergency

Tags: Emergency Descent Emergency Evacuation Airport Emergency Medical Response MAYDAY declaration PAN declaration “Emergency” declaration Slide Malfunction RFFS Procedures Evacuation difficulties in Water Delay in Declaration of Emergency

Add CS Tags

Tags: Disruptive Pax Turbulence Injury - Cabin Crew Turbulence Injury - Pax with Seat Belts on Turbulence Injury - Pax with Seat Belts off Cabin Stowage - Pax Items Toilet compartment fire Cabin furnishings fire Evacuation slides deployed Pax oxygen mask drop Unauthorised PED use IFE fire Flight deck comms difficulty Cabin air contamination Malicious interference Hand held extinguisher used Evacuation on Cabin Crew initiative Flight Crew Evacuation Command Cabin Crew Incapacitation Cabin Crew Medical Fitness Passenger Illness Faulty or misused PED

Tags: Disruptive Pax Turbulence Injury - Cabin Crew Turbulence Injury - Pax with Seat Belts on Turbulence Injury - Pax with Seat Belts off Cabin Stowage - Pax Items Toilet compartment fire Cabin furnishings fire Evacuation slides deployed Pax oxygen mask drop Unauthorised PED use IFE fire Flight deck comms difficulty Cabin air contamination Malicious interference Hand held extinguisher used Evacuation on Cabin Crew initiative Flight Crew Evacuation Command Cabin Crew Incapacitation Cabin Crew Medical Fitness Passenger Illness Faulty or misused PED

Add AW Tags

System(s): Airframe Air Conditioning and Pressurisation Autoflight Communications Electrical Power Equipment / Furnishings Fire Protection Flight Controls Fuel Hydraulic Power Ice and Rain Protection Indicating / Recording Systems Landing Gear Landing Lights Navigation Oxygen Airborne Auxiliary Power (APU) Propellers Rotors Engine - General Engine Fuel and Control Bleed Air Other Emergency Evacuation Contributor(s): Maintenance Error (valid guidance available) Maintenance Error (invalid guidance available) Inadequate Maintenance Schedule Inadequate Maintenance Inspection Inadequate QRH Drills OEM Design fault Damage Tolerance Contributing ADD Component Fault in service Component Fault after installation Pilot verbal-only defect communication Corrosion/Disbonding/Fatigue Cross Connection Engine Compressor Washing

System(s): Airframe Air Conditioning and Pressurisation Autoflight Communications Electrical Power Equipment / Furnishings Fire Protection Flight Controls Fuel Hydraulic Power Ice and Rain Protection Indicating / Recording Systems Landing Gear Landing Lights Navigation Oxygen Airborne Auxiliary Power (APU) Propellers Rotors Engine - General Engine Fuel and Control Bleed Air Other Emergency Evacuation Contributor(s): Maintenance Error (valid guidance available) Maintenance Error (invalid guidance available) Inadequate Maintenance Schedule Inadequate Maintenance Inspection Inadequate QRH Drills OEM Design fault Damage Tolerance Contributing ADD Component Fault in service Component Fault after installation Pilot verbal-only defect communication Corrosion/Disbonding/Fatigue Cross Connection Engine Compressor Washing

Add Safety Net Mitigation

Malfunction of Relevant Safety Net: None Yes No GPWS: None Effective Partially effective Available but ineffective TAWS: None Effective Partially effective Available but ineffective TAWS with RAAS: None Effective Partially effective Available but ineffective TCAS: None Effective Partially effective Available but ineffective STCA: None Effective Partially effective Available but ineffective MSAW: None Effective Partially effective Available but ineffective APM: None Effective Partially effective Available but ineffective APW: None Effective Partially effective Available but ineffective Mode 'S' EHS: None Effective Partially effective Available but ineffective Wind Shear Escape Guidance: None Effective Partially effective Available but ineffective Stall Protection: None Effective Partially effective Available but ineffective A-SMGCS: None Effective Partially effective Available but ineffective EMAS: None Effective Partially effective Available but ineffective TOCWS: None Effective Partially effective Available but ineffective

Add Causal Factor Group(s)

Causal Factor Group(s): Aircraft Operation Aircraft Technical Air Traffic Management Airport Operation

Causal Factor Group(s): Aircraft Operation Aircraft Technical Air Traffic Management Airport Operation

Add Safety Recommendations

Safety Recommendations: None Made Aircraft Operation Aircraft Airworthiness Air Traffic Management Airport Management

Safety Recommendations: None Made Aircraft Operation Aircraft Airworthiness Air Traffic Management Airport Management

Accident Report text:

==Description== On 19 August 1980, a [[L101|Lockheed L1011]] operated by Saudi Arabian Airlines took off from Riyadh, Saudi Arabia. Seven minutes after the take off an aural warning indicated a [[Smoke|smoke]] in the aft cargo compartment. The crew spent 5 minutes 20 seconds confirming the first [[In-Flight Fire|fire]] warning before the Captain elected to return to Riyadh. The thrust lever for the number 2 engine (center engine) became stuck as the fire burned through the operating cable, and the engine was shut down on final approach. The aircraft returned to Riyadh and executed a safe landing. After touchdown, the L1011 continued to taxi, and stopped on a taxiway 2 minutes 40 seconds after landing. The engines were not shut down for another 3 minutes and 15 seconds, preventing the rescue from reaching the aircraft. All 301 persons on board perished due toxic fumes inhalation and uncontrolled fire. ==Synopsis== The following is an extract from the official report of the [[Accident|accident]] published by the Presidency of Civil Aviation, Saudi Arabia: '''"The initial climb toward Jeddah was uneventful until''' […]''', 6:54 minutes after take-off''' [approximately 24 minutes before the airplane came to a stop back at Riyadh]'''when the flight crew was alerted by both visual and aural warnings indicating smoke in the aft cargo compartment (C-3).''' '''The confirmation time (total 5 minutes and 20 seconds) of the first fire warning before a decision was made to return to Riyadh included also Flight Engineer entering the passenger cabin to investigate the situation. When he returned to the flight deck he reported smoke and fire in the cabin. The airport at Riyadh was contacted, and informed that the airplane was returning because of a fire in the cabin and requested that crash, fire, and rescue be alerted.''' '''After turn back to Riyadh, the flight engineer returned to the passenger cabin to assess the extent of the fire. Upon return to the flight deck he reported there was just smoke in the aft end of the aircraft. This was approximately 17 minutes before the airplane came to a stop after landing. A flight attendant reported to the flight crew that there was a general panic among the passengers. Fourteen minutes prior to landing at Riyadh, another aural smoke detector warning occurred, and was recorded on the cockpit voice recorder ([[Cockpit Voice Recorder (CVR)|CVR]]). Thirteen minutes before the airplane came to a stop, the Captain stated that the throttle of No. 2 engine was stuck, and that he was going to shut the engine down. Also, at 13 minutes before the airplane came to a stop on the taxiway, another flight attendant reported she could not go further aft than doors L2 and R2 because people were fighting in the aisles. Immediately thereafter, another flight attendant came into the flight deck and reported fire in the cabin. At 11 minutes before the airplane came to a stop, the CVR recorded an announcement by the cabin crew to stay calm and to stay seated. Ten minutes before stopping on the taxiway, a flight attendant came forward and advised the crew, "there is too much smoke in the back." The flight attendant repeated instructions to the passengers to stay in their seats to prepare for landing. Three minutes 33 seconds before the airplane came to a stop another aural smoke detector warning was recorded on the CVR.''' '''A flight attendant repeated instructions to the passengers to stay in their seats to prepare for landing. The aircraft did not make an emergency stop but instead taxied off the runway to a taxiway. Two minutes forty seconds after landing, the aircraft came to a stop on the taxiway. After stopping, a witness parked his car just behind and to the left of the aircraft. He observed a fire through the windows on the left side of the cabin between the L3 and L4 doors. He said there was no fire outside the aircraft at that time. He could not see any movement in the cockpit or cabin.''' '''Immediately after stopping, an announcement was made to the tower “We are shutting down the engines and are now evacuating”. '''One and a half minutes after stopping the control tower relayed to the aircraft that the tail of the airplane was on fire. The aircraft responded, "Affirmative, we are trying to evacuate now". This was the last transmission received from the aircraft. ''' ''To view Saudi Arabian Airlines L1011 Flight Path Animation, click [http://accidents-ll.faa.gov/Saudi163/Saudi163_FlightPath_pop_up.htm here]. The animation is a courtesy of FAA Lessons Learned from Transport Airline Accidents (http://accidents-ll.faa.gov).'' Three minutes and fifteen seconds after the aircraft stopped the engines were shut down. Smoke rose from the top of the fuselage, followed almost immediately by flames. '''"Attempts by the crash, fire, rescue personnel (CFR) to enter the aircraft and open the doors were unsuccessful until the No. 2 door on the right side of the aircraft was opened''' […] '''about 23 minutes after all engines had been shut down."''' In a section of the Report titled “The Flight Actions by the Crew” (page 69) it is stated: […] '''"The Captain should have instructed his cabin crew to prepare for an evacuation immediately upon landing. He should have called for the use of oxygen by his cockpit crew and instructed his cabin crew to use oxygen when needed. The inhalation of toxic gasses, at times, is insidious and causes physical and mental impairment which would be alleviated by the proper use of oxygen.''' […] […] '''After landing, the Captain should have stopped his aircraft as soon as possible and initiated an emergency evacuation. However, he wasted critical time in taxiing the aircraft clear of the runway."''' The investigation determined that the C-3 cargo compartment on the L1011 (Figure 1), which was certified as a Class D (per 14 CFR part, § 25.855), did not contain the fire within the cargo compartment as intended by the regulations. The regulations intended that the liner material contain the fire within the cargo compartment, and the fire would quickly consume the oxygen (oxygen starvation) within the compartment before the fire had a chance to get out of control. Testing demonstrated that the Nomex cargo liner fabric material was inadequate to contain the fire within the cargo compartment. As a result of the fire burning through the cargo liner, creating a breach into the cabin, additional oxygen was available to feed the fire in the cargo compartment. The fire quickly spread to the passenger cabin, and the burning material produced toxic fumes, including carbon monoxide. [[File:Lockheed Cargo Config.jpg|none|thumb|600px|alt=Lockheed Cargo Configuration|'''''Figure 1.''''' Lockheed L-1011 Cargo Configuration]] As to Probable Cause to the accident, the Report states: '''"The Presidency of Civil Aviation determines that the probable cause of this accident was the initiation of fire in the C-3 cargo compartment. The source of the ignition of the fire is undetermined.''' '''Factors contributing to the final fatal results of this accident were:''' * '''the failure of the Captain to prepare the cabin crew for immediate evacuation upon landing, and his failure in not making a maximum stop landing on the runway, with immediate evacuation,''' * '''the failure of the Captain to properly utilise his flight crew throughout the emergency''' * '''the failure of CFR headquarters management personnel to ensure that its personnel had adequate equipment and training to function as required during an emergency."''' The Presidency of Civil Aviation, Saudi Arabia, made six recommendations regarding the operational practices of the airline. A complete list of recommendations is found in the full accident report, page 78. (see Further Reading). The recommendations covered a number of subjects: * Revision of training programs for aircrew, stressing emergencies and command training * Additional assertiveness training for junior flight crew members * Crew matching to ensure cockpit experience levels * Avoid rehiring of flight crew members who have been previously dismissed due to substandard performance * Review and amend emergency checklists In addition the [[NTSB|National Transportation and Safety Board]] (NTSB) issued a recommendation to re-evaluate the "Class-D" certification of the L1011 C-3 cargo compartment with a view toward either changing the classification to "C", requiring detection and extinguishing equipment, or changing the compartment liner material to ensure containment of a fire of the types likely in the compartment while in-flight. ==Related Articles== '''FIRE''' * [[Cabin Fire|Cabin Fire]]; * [[In-Flight Fire: Guidance for Flight Crews|In-Flight Fire: Guidance for Flight Crews]]; * [[In-Flight Fire: Guidance for Controllers|In-Flight Fire: Guidance for Controllers]]; * [[Accident and Serious Incident Reports: FIRE|Accident and Serious Incident Reports: FIRE]]. '''HF''' * [[CRM|CRM]]; * [[Crew Incapacitation|Crew Incapacitation]]; ==Further Reading== * [http://www.skybrary.aero/bookshelf/books/1342.pdf Aircraft Accident Report Saudi Arabian Airlines, L1011, Riyadh Saudi Arabia, 19 Aug. 1980], by Presidency of Civil Aviation, Saudi Arabia (ATT:Large file, 45Mb) * see also FAA Lessons Learned from Transport Airplane Accidents: [http://accidents-ll.faa.gov/ll_main.cfm?TabID=4&LLID=27&LLTypeID=0 Saudi Arabian Airlines, Flight 163, Lockheed L-1011, HZ-AHK]

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