Aircraft Accident Report No 2/90 (EW/C1094)
on the accident to
Boeing 747-121, N739PA
at Lockerbie, Dumfriesshire, Scotland
on 21December 1988
|Operator:||Pan American World Airways|
|Aircraft Type:||Boeing 747-121|
|Nationality:||United States of America|
|Registration:||N 739 PA|
|Place of Accident||Lockerbie, Dumfries, Scotland|
|Latitude||55° 07' N|
|Longitude||003° 21' W|
|Date and Time (UTC):||21 December 1988 at 19.02:50 hrs|
|All times in this report are UTC|
The accident was notified to the Air Accidents Investigation Branch at 19.40 hrs on the 21 December 1988 and the investigation commenced that day. The members of the AAIB team are listed at Appendix A.
The aircraft, Flight PA103 from London Heathrow to New York, had been in level cruising flight at flight level 310 (31,000 feet) for approximately seven minutes when the last secondary radar return was received just before 19.03 hrs. The radar then showed multiple primary returns fanning out downwind. Major portions of the wreckage of the aircraft fell on the town of Lockerbie with other large parts landing in the countryside to the east of the town. Lighter debris from the aircraft was strewn along two trails, the longest of which extended some 130 kilometres to the east coast of England. Within a few days items of wreckage were retrieved upon which forensic scientists found conclusive evidence of a detonating high explosive. The airport security and criminal aspects of the accident are the subject of a separate investigation and are not covered in this report which concentrates on the technical aspects of the disintegration of the aircraft.
The report concludes that the detonation of an improvised explosive device led directly to the destruction of the aircraft with the loss of all 259 persons on board and 11 of the residents of the town of Lockerbie. Five recommendations are made of which four concern flight recorders, including the funding of a study to devise methods of recording violent positive and negative pressure pulses associated with explosions. The final recommendation is that Airworthiness Authorities and aircraft manufacturers undertake a systematic study with a view to identifying measures that might mitigate the effects of explosive devices and improve the tolerance of the aircraft's structure and systems to explosive damage.
1. FACTUAL INFORMATION
1.1 History of the Flight
Boeing 747, N739PA, arrived at London Heathrow Airport from San Francisco and parked on stand Kilo 14, to the south-east of Terminal 3. Many of the passengers for this aircraft had arrived at Heathrow from Frankfurt, West Germany on a Boeing 727, which was positioned on stand Kilo 16, next to N739PA. These passengers were transferred with their baggage to N739PA which was to operate the scheduled Flight PA103 to New York Kennedy. Passengers from other flights also joined Flight PA103 at Heathrow. After a 6 hour turnround, Flight PA103 was pushed back from the stand at 18.04 hrs and was cleared to taxy on the inner taxiway to runway 27R. The only relevant Notam warned of work in progress on the outer taxiway. The departure was unremarkable.
Flight PA103 took-off at 18.25 hrs. As it was approaching the Burnham VOR it took up a radar heading of 350° and flew below the Bovingdon holding point at 6000 feet. It was then cleared to climb initially to flight level (FL) 120 and subsequently to FL 310. The aircraft levelled off at FL 310 north west of Pole Hill VOR at 18.56 hrs. Approximately 7 minutes later, Shanwick Oceanic Control transmitted the aircraft's oceanic clearance but this transmission was not acknowledged. The secondary radar return from Flight PA103 disappeared from the radar screen during this transmission. Multiple primary radar returns were then seen fanning out downwind for a considerable distance. Debris from the aircraft was strewn along two trails, one of which extended some 130 km to the east coast of England. The upper winds were between 250° and 260° and decreased in strength from 115 kt at FL 320 to 60 kt at FL 100 and 15 to 20 kt at the surface.
Two major portions of the wreckage of the aircraft fell on the town of Lockerbie; other large parts, including the flight deck and forward fuselage section, landed in the countryside to the east of the town. Residents of Lockerbie reported that, shortly after 19.00 hrs, there was a rumbling noise like thunder which rapidly increased to deafening proportions like the roar of a jet engine under power. The noise appeared to come from a meteor-like object which was trailing flame and came down in the north-eastern part of the town. A larger, dark, delta shaped object, resembling an aircraft wing, landed at about the same time in the Sherwood area of the town. The delta shaped object was not on fire while in the air, however, a very large fireball ensued which was of short duration and carried large amounts of debris into the air, the lighter particles being deposited several miles downwind. Other less well defined objects were seen to land in the area.
1.2 Injuries to persons
1.3 Damage to aircraft
The aircraft was destroyed
1.4 Other damage
The wings impacted at the southern edge of Lockerbie, producing a crater whose volume, calculated from a photogrammetric survey, was approximately 560 cubic metres. The weight of material displaced by the wing impact was estimated to be well in excess of 1500 tonnes. The wing impact created a fireball, setting fire to neighbouring houses and carrying aloft debris which was then blown downwind for several miles. It was subsequently established that domestic properties had been so seriously damaged as a result of fire and/or impact that 21 had to be demolished and an even greater number of homes required substantial repairs. Major portions of the aircraft, including the engines, also landed on the town of Lockerbie and other large parts, including the flight deck and forward fuselage section, landed in the countryside to the east of the town. Lighter debris from the aircraft was strewn as far as the east coast of England over a distance of 130 kilometres.
1.5 Personnel information
|1.5.1||Commander:||Male, aged 55 years|
|Licence:||USA Airline Transport Pilot's Licence|
|Aircraft ratings:||Boeing 747, Boeing 707, Boeing 720, Lockheed L1011 and Douglas DC3|
|Medical Certificate:||Class 1,valid to April 1989, with the limitation that the holder shall wear lenses that correct for distant vision and possess glasses that correct for near vision|
|Total all types:||10,910 hours|
|Total on type:||4,107 hours|
|Total last 28 days||82 hours|
|Duty time:||Commensurate with company requirements|
|Last base check:||11 November 1988|
|Last route check:||30 June 1988|
|Last emergencies check:||8 November 1988|
|1.5.2||Co-pilot:||Male, aged 52 years|
|Licence:||USA Airline Transport Pilot's Licence|
|Aircraft ratings:||Boeing 747, Boeing 707, Boeing 727|
|Medical Certificate:||Class 1, valid to April 1989, with the limitation that the holder shall possess correcting glasses for near vision|
|Total all types:||11,855 hours|
|Total on type:||5,517 hours|
|Total last 28 days:||51 hours|
|Duty time:||Commensurate with company requirements|
|Last base check:||30 November 1988|
|Last route check:||Not required|
|Last emergencies check:||27 November 1988|
|1.5.3||Flight Engineer:||Male, aged 46 years|
|Licence:||USA Flight Engineer's Licence|
|Medical certificate:||Class 2, valid to June 1989, with the limitation that the holder shall wear correcting glasses for near vision|
|Total all types:||8,068 hours|
|Total on type:||487 hours|
|Total last 28 days:||53 hours|
|Duty time:||Commensurate with company requirements|
|Last base check:||30 October 1988|
|Last route check:||Not required|
|Last emergencies check:||27 October 1988|
1.5.4 Flight Attendants: There were 13 Flight Attendants on the aircraft, all of whom met company proficiency and medical requirements
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1.6 Aircraft information
|Aircraft type:||Boeing 747-121|
|Constructor's serial number:||19646|
|Engines:||4 Pratt and Whitney JT9D-7A turbofan|
The Boeing 747 aircraft, registration N739PA, was a conventionally designed long range transport aeroplane. A diagram showing the general arrangement is shown at Appendix B, Figure B-1 together with the principal dimensions of the aircraft.
The fuselage of the aircraft type was of approximately circular section over most of its length, with the forward fuselage having a diameter of 21› feet where the cross-section was constant. The pressurised section of the fuselage (which included the forward and aft cargo holds) had an overall length of 190 feet, extending from the nose to a point just forward of the tailplane. In normal cruising flight the service pressure differential was at the maximum value of 8.9 pounds per square inch. The fuselage was of conventional skin, stringer and frame construction, riveted throughout, generally using countersunk flush riveting for the skin panels. The fuselage frames were spaced at 20 inch intervals and given the same numbers as their stations, defined in terms of the distance in inches from the datum point close to the nose of the aircraft [Appendix B, Figure B-2]. The skin panels were joined using vertical butt joints and horizontal lap joints. The horizontal lap joints used three rows of rivets together with a cold bonded adhesive.
Accommodation within the aircraft was predominately on the main deck, which extended throughout the whole length of the pressurised compartment. A separate upper deck was incorporated in the forward part of the aircraft. This upper deck was reached by means of a spiral staircase from the main deck and incorporated the flight crew compartment together with additional passenger accommodation. The cross-section of the forward fuselage differed considerably from the near circular section of the remainder of the aircraft, incorporating an additional smaller radius arc above the upper deck section joined to the main circular arc of the lower cabin portion by elements of straight fuselage frames and flat skin.
In order to preserve the correct shape of the aircraft under pressurisation loading, the straight portions of the fuselage frames in the region of the upper deck floor and above it were required to be much stiffer than the frame portions lower down in the aircraft. These straight sections were therefore of very much more substantial construction than most of the curved sections of frames lower down and further back in the fuselage. There was considerable variation in the gauge of the fuselage skin at various locations in the forward fuselage of the aircraft.
The fuselage structure of N739PA differed from that of the majority of Boeing 747 aircraft in that it had been modified to carry special purpose freight containers on the main deck, in place of seats. This was known as the Civil Reserve Air Fleet (CRAF) modification and enabled the aircraft to be quickly converted for carriage of military freight containers on the main deck during times of national emergency. The effect of this modification on the structure of the fuselage was mainly to replace the existing main deck floor beams with beams of more substantial cross-section than those generally found in passenger carrying Boeing 747 aircraft. A large side loading door, generally known as the CRAF door, was also incorporated on the left side of the main deck aft of the wing.
Below the main deck, in common with other Boeing 747 aircraft, were a number of additional compartments, the largest of which were the forward and aft freight holds used for the storage of cargo and baggage in standard air-transportable containers. These containers were placed within the aircraft hold by means of a freight handling system and were carried on a system of rails approximately 2 feet above the outer skin at the bottom of the aircraft, there being no continuous floor, as such, below these baggage containers. The forward freight compartment had a length of approximately 40 feet and a depth of approximately 6 feet. The containers were loaded into the forward hold through a large cargo door on the right side of the aircraft.
1.6.3 Internal fuselage cavities
Because of the conventional skin, frame and stringer type of construction, common to all large public transport aircraft, the fuselage was effectively divided into a series of 'bays'. Each bay, comprising two adjacent fuselage frames and the structure between them, provided, in effect, a series of interlinking cavities bounded by the frames, floor beams, fuselage skins and cabin floor panels etc. The principal cavities thus formed were:
|(i)||A semi-circular cavity formed in between the fuselage frames in the lower lobe of the hull, i.e. from the crease beam (at cabin floor level) on one side down to the belly beneath the containers and up to the opposite crease beam, bounded by the fuselage skin on the outside and the containers/cargo liner on the inside [Appendix B, Figure B-3, detail A].|
|(ii)||A horizontal cavity between the main cabin floor beams, the cabin floor panels and the cargo bay liner. This extended the full width of the fuselage and linked the upper ends of the lower lobe cavity [Appendix B, Figure B-3, detail B].|
|(iii)||A narrow vertical cavity between the two containers [Appendix B, Figure B-3, detail C].|
|(iv)||A further narrow cavity around the outside of the two containers, between the container skins and the cargo bay liner, communicating with the lower lobe cavity [Appendix B, Figure B-3, detail D].|
|(v)||A continuation of the semi-circular cavity into the space behind the cabin wall liner [Appendix B, Figure B-3, detail E]. This space was restricted somewhat by the presence of the window assembly, but nevertheless provided a continuous cavity extending upwards to the level of the upper deck floor. Forward of station 740, this cavity was effectively terminated at its upper end by the presence of diaphragms which formed extensions of the upper deck floor panels; aft of station 740, the cavity communicated with the ceiling space and the cavity in the fuselage crown aft of the upper deck.|
The main passenger cabin formed a large chamber which communicated directly with each of the sub floor bays, and also with the longitudinal manifold cavity, via the air conditioning and cabin/cargo bay de-pressurisation vent passages in the crease beam area. (It should be noted that a similar communication did not exist between the upper and lower cabins because there were no air conditioning/depressurisation passages to bypass the upper deck floor.)
1.6.4 Aircraft weight and centre of gravity
The aircraft was loaded within its permitted centre of gravity limits as follows:
|Operating empty weight||366,228||166,120|
|243 passengers (1)||40,324||18,291|
|Load in compartments:|
|Total in compartments (2)||66,452||30,143|
|Total traffic load||106,776||48,434|
|Zero fuel weight||472,156||214,554|
|Actual take-off weight(4)||713,002||323,416|
|Maximum take-off weight||733,992||332,937|
Despatch information stated that the cargo did not include dangerous goods, perishable cargo, live animals or known security exceptions.
1.6.5 Maintenance details
N739PA first flew in 1970 and spent its whole service life in the hands of Pan American World Airways Incorporated. Its Certificate of Airworthiness was issued on 12 February 1970 and remained in force until the time of the accident, at which time the aircraft had completed a total of 72,464 hours flying and 16,497 flight cycles. Details of the last 4 maintenance checks carried out during the aircraft's life are shown below:
|27 Sept 88||C Check (Interior upgrade)||71,502||16,347|
|2 Nov 88||B Service Check||71,919||16,406|
|27 Nov 88||Base 1||72,210||16,454|
|13 Dec 88||Base 2||72,374||16,481|
All Airworthiness Directives relating to the Boeing 747 fuselage structure between stations 500 and 1000 have been reviewed and their applicability to this aircraft checked. In addition, Service Bulletins relating to the structure in this area were also reviewed. The applicable Service Bulletins, some of which implement the Airworthiness Directives are listed below together with their subjects. The dates, total aircraft times and total aircraft cycles at which each relevant inspection was last carried out have been reviewed and their status on aircraft N739PA at the time of the accident has been established.
N739PA Service Bulletin compliance:
|SB 53-2064||Front Spar Pressure Bulkhead Chord Reinforcement and Drag Splice Fitting Rework.|
|Modification accomplished on 6 July 1974.|
|Post-modification repetitive inspection IAW (in accordance with) AD 84-18-06 last accomplished on 19 November 1985 at 62,030 TAT hours (Total Aircraft Time) and 14,768 TAC (Total Aircraft Cycles).|
|SB 53-2088||Frame to Tension Tie Joint Modification - BS760 to 780.|
|Repetitive inspection IAW AD 84-19-01 last accomplished on 19 June 1985 at 60,153 hours TAT and 14,436 TAC.|
|SB 53-2200||Lower Cargo Doorway Lower Sill Truss and Latch Support Fitting Inspection Repair and Replacement.|
|Repetitive inspection IAW AD 79-17-02 R2 last accomplished 2 November 1988 at 71,919 hours TAT and 16,406 TAC.|
|SB 53-2234||Fuselage - Auxiliary Structure - Main Deck Floor - BS 480 Floor Beam Upper Chord Modification.|
|Repetitive inspection per SB 53A2263 IAW AD 86-23-06 last accomplished on 26 September 1987 at 67,376 hours TAT and 15,680 TAC.|
|SB 53-2237||Fuselage - Main Frame - BS 540 thru 760 and 1820 thru 1900 Frame Inspection and Reinforcement.|
|Repetitive inspection IAW AD 86-18-01 last accomplished on 27 February 1987 at 67,088 hours TAT and 15,627 TAC.|
|SB 53-2267||Fuselage - Skin - Lower Body Longitudinal Skin Lap Joint and Adjacent Body Frame Inspection and Repair.|
|Terminating modification accomplished 100% under wing-to-body fairings and approximately 80% in forward and aft fuselage sections on 26 September 1987 at 67,376 hours TAT and 15,680 TAC.|
|Repetitive inspection of unmodified lap joints IAW AD 86-09-07 R1 last accomplished on 18 August 1988 at 71,043 hours TAT and 16,273 TAC.|
|SB 53A2303||Fuselage - Nose Section - station 400 to 520 Stringer 6 Skin Lap Splice Inspection, Repair and Modification.|
|Repetitive inspection IAW AD 89-05-03 last accomplished on 26 September 1987 at 67,376 hours TAT and 15,680 TAC.|
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1.7 Meteorological Information
1.7.1 General weather conditions
An aftercast of the general weather conditions in the area of Lockerbie at about 19.00 hrs was obtained from the Meteorological Office, Bracknell. The synoptic situation included a warm sector covering northern England and most of Scotland with a cold front some 200 nautical miles to the west of the area moving eastwards at about 35 knots. The weather consisted of intermittent rain or showers. The cloud consisted of 4 to 6 oktas of stratocumulus based at 2,200 feet with 2 oktas of altocumulus between 15,000 and 18,000 feet. Visibility was over 15 kilometers and the freezing level was at 8,500 feet with a sub-zero layer between 4,000 and 5,200 feet.
There was a weakening jet stream of around 115 knots above Flight Level 310. From examination of the wind profile (see below), there appeared to be insufficient shear both vertically and horizontally to produce any clear air turbulence but there may have been some light turbulence.
|300||260°/ 90 knots|
|240||250°/ 80 knots|
|180||260°/ 60 knots|
|100||250°/ 60 knots|
|050||260°/ 40 knots|
|Surface||240°/ 15 to 20 gusting 25 to 30 knots|
The aircraft communicated normally on London Heathrow aerodrome, London control and Scottish control frequencies. Tape recordings and transcripts of all radio telephone (RTF) communications on these frequencies were available.
At 18.58 hrs the aircraft established two-way radio contact with Shanwick Oceanic Area Control on frequency 123.95 MHz. At 19.02:44 hrs the clearance delivery officer at Shanwick transmitted to the aircraft its oceanic route clearance. The aircraft did not acknowledge this message and made no subsequent transmission.
1.9.1 ATC recording replay
Scottish Air Traffic Control provided copy tapes with time injection for both Shanwick and Scottish ATC frequencies. The source of the time injection on the tapes was derived from the British Telecom "TIM" signal.
The tapes were replayed and the time signals corrected for errors at the time of the tape mounting.
1.9.2 Analysis of ATC tape recordings
From the cockpit voice recorder (CVR) tape it was known that Shanwick was transmitting Flight PA103's transatlantic clearance when the CVR stopped. By synchronising the Shanwick tape and the CVR it was possible to establish that a loud sound was heard on the CVR cockpit area microphone (CAM) channel at 19.02:50 hrs ±1 second.
As the Shanwick controller continued to transmit Flight PA103's clearance instructions through the initial destruction of the aircraft it would not have been possible for a distress call to be received from N739PA on the Shanwick frequency. The Scottish frequency tape recording was listened to from 19.02 hrs until 19.05 hrs for any unexplained sounds indicating an attempt at a distress call but none was heard.
A detailed examination and analysis of the ATC recording together with the flight recorder, radar, and seismic recordings is contained in Appendix C.
1.10 Aerodrome information
1.11 Flight recorders
The Digital Flight Data Recorder (DFDR) and the Cockpit Voice Recorder (CVR) were found close together at UK Ordnance Survey (OS) Grid Reference 146819, just to the east of Lockerbie, and recovered approximately 15 hours after the accident. Both recorders were taken directly to AAIB Farnborough for replay. Details of the examination and analysis of the flight recorders together with the radar, ATC and seismic recordings are contained in Appendix C.
1.11.1 Digital flight data recorder
The flight data recorder installation conformed to ARINC 573B standard with a Lockheed Model 209 DFDR receiving data from a Teledyne Controls Flight Data Acquisition Unit (FDAU). The system recorded 22 parameters and 27 discrete (event) parameters. The flight recorder control panel was located in the flight deck overhead panel. The FDAU was in the main equipment centre at the front end of the forward hold and the flight recorder was mounted in the aft equipment centre.
Decoding and reduction of the data from the accident flight showed that no abnormal behaviour of the data sensors had been recorded and that the recorder had simply stopped at 19.02:50 hrs ±1 second.
1.11.2 Cockpit voice recorder
The aircraft was equipped with a 30 minute duration 4 track Fairchild Model A100 CVR, and a Fairchild model A152 cockpit area microphone (CAM). The CVR control panel containing the CAM was located in the overhead panel on the flight deck and the recorder itself was mounted in the aft equipment centre.
The channel allocation was as follows:-
|Channel 1||Flight Engineer's RTF.|
|Channel 2||Co-Pilot's RTF.|
|Channel 3||Pilot's RTF.|
|Channel 4||Cockpit Area Microphone.|
The CVR tape was listened to for its full duration and there was no indication of anything abnormal with the aircraft, or unusual crew behaviour. The tape record ended, at 19.02:50 hrs ±1 second, with a sudden loud sound on the CAM channel followed almost immediately by the cessation of recording whilst the crew were copying their transatlantic clearance from Shanwick ATC.
1.12 Wreckage and impact information
1.12.1 General distribution of wreckage in the field
The complete wing primary structure, incorporating the centre section, impacted at the southern edge of Lockerbie. Major portions of the aircraft, including the engines, also landed in the town. Large portions of the aircraft fell in the countryside to the east of the town and lighter debris was strewn to the east as far as the North Sea. The wreckage was distributed in two trails which became known as the northern and southern trails respectively and these are shown in Appendix B, Figure B-4. A computer database of approximately 1200 significant items of wreckage was compiled and included a brief description of each item and the location where it was found
Appendix B, Figures B-5 to B-8 shows photographs of a model of the aircraft on which the fracture lines forming the boundaries of the separate items of structure have been marked. The model is colour coded to illustrate the way in which the wreckage was distributed between the town of Lockerbie and the northern and southern trails.
22.214.171.124 The crater
The aircraft wing impacted in the Sherwood Crescent area of the town leaving a crater approximately 47 metres (155 feet) long with a volume calculated to be 560 cubic metres.
The projected distance, measured parallel from one leading edge to the other wing tip, of the Boeing 747-100 was approximately 143 feet, whereas the span is known to be 196 feet. This suggests that impact took place with the wing structure yawed. Although the depth of the crater varied from one end to the other, its widest part was clearly towards the western end suggesting that the wing structure impacted whilst orientated with its root and centre section to the west.
The work carried out at the main crater was limited to assessing the general nature of its contents. The total absence of debris from the wing primary structure found remote from the crater confirmed the initial impression that the complete wing box structure had been present at the main impact.
The items of wreckage recovered from or near the crater are coloured grey on the model at Appendix B, Figures B-5 to B-8.
126.96.36.199 The Rosebank Crescent site
A 60 feet long section of fuselage between frame 1241 (the rear spar attachment) and frame 1960 (level with the rear edge of the CRAF cargo door) fell into a housing estate at Rosebank Crescent, just over 600 metres from the crater. This section of the fuselage was that situated immediately aft of the wing, and adjoined the wing and fuselage remains which produced the crater. It is colour coded yellow on the model at Appendix B, Figures B-5 to B-8. All fuselage skin structure above floor level was missing except for the following items:
Section containing 3 windows between door 4L and
The CRAF door itself (latched) apart from the top area containing the hinge;
Window belt containing 8 windows aft of 4R door aperture
Window belt containing 3 windows forward of 4R door aperture;
Other items found in the wreckage included both body landing gears, the right wing landing gear, the left and right landing gear support beams and the cargo door (frames 1800-1920) which was latched. A number of pallets, luggage containers and their contents were also recovered from this site.
188.8.131.52 Forward fuselage and flight deck section.
The complete fuselage forward of approximately station 480 (left side) to station 380 (right side) and incorporating the flight deck and nose landing gear was found as a single piece [Appendix B, Figure B-9] in a field approximately 4 km miles east of Lockerbie at OS Grid Reference 174808. It was evident from the nature of the impact damage and the ground marks that it had fallen almost flat on its left side but with a slight nose-down attitude and with no discernible horizontal velocity. The impact had caused almost complete crushing of the structure on the left side. The radome and right nose landing gear door had detached in the air and were recovered in the southern trail.
Examination of the torn edges of the fuselage skin did not indicate the presence of any pre-existing structural or material defects which could have accounted for the separation of this section of the fuselage. Equally so, there were no signs of explosive blast damage or sooting evident on any part of the structure or the interior fittings. It was noted however that a heavy, semi-eliptical scuff mark was present on the lower right side of the fuselage at approximately station 360. This was later matched to the intake profile of the No 3 engine.
The status of the controls and switches on the flight deck was consistent with normal operation in cruising flight. There were no indications that the crew had attempted to react to rapid decompression or loss of control or that any emergency preparations had been actioned prior to the catastrophic disintegration.
184.108.40.206 Northern trail
The northern trail was seen to be narrow and clearly defined, to emanate from a point very close to the main impact crater and to be orientated in a direction which agreed closely with the mean wind aftercast for the height band from sea level to 20,000 ft. Also at the western end of the northern trail were the lower rear fuselage at Rosebank Crescent, and the group of Nos. 1, 2 and 4 engines which fell in Lockerbie.
The trail contained items of structure distributed throughout its length, from the area slightly east of the crater, to a point approximately 16 km east, beyond which only items of low weight / high drag such as insulation, interior trim, paper etc, were found. For all practical purposes this trail ended at a range of 25 km.
The northern trail contained mainly wreckage from the rear fuselage, fin and the inner regions of both tailplanes together with structure and skin from the upper half of the fuselage forward to approximately the wing mid-chord position. A number of items from the wing were also found in the northern trail, including all 3 starboard Kreuger flaps, most of the remains of the port Kreuger flaps together with sections of their leading edge attachment structures, one portion of outboard aileron approximately 10 feet long, the aft ends of the flap-track fairings (one with a slide raft wrapped around it), and fragments of glass reinforced plastic honeycombe structure believed to be from the flap system, i.e. fore-flaps, aft-flaps, mid-flaps or adjacent fairings. In addition, a number of pieces of the engine cowlings and both HF antennae (situated projecting aft from the wing-tips) were found in this trail.
All items recovered from the northern trail, with the exception of the wing, engines, and lower rear fuselage in Rosebank Crescent, are coloured red on the model of the aircraft in Appendix B, Figures B-5 to B-8.
220.127.116.11 Southern trail
The southern trail was easily defined, except within 12 km of Lockerbie where it tended to merge with the northern trail. Further east, it extended across southern Scotland and northern England, essentially in a straight band as far as the North Sea. Most of the significant items of wreckage were found in this trail within a range of 30 km from the main impact crater. Items recovered from the southern trail are coloured green on the model of the aircraft at Appendix B, Figures B-5 to B-8.
The trail contained numerous large items from the forward fuselage. The flight deck and nose of the aircraft fell in the curved part of this trail close to Lockerbie. Fragments of the whole of the left tailplane and the outboard portion of the right tailplane were distributed almost entirely throughout the southern trail. Between 21 and 27 km east of the main impact point (either side of Langholm) substantial sections of tailplane skin were found, some bearing distinctive signs of contact with debris moving outwards and backwards relative to the fuselage. Also found in this area were numerous isolated sections of fuselage frame, clearly originating from the crown region above the forward upper deck.
18.104.22.168 Datum line
All grid references relating to items bearing actual explosive evidence, together with those attached to heavily distorted items found to originate immediately adjacent to them on the structure, were plotted on an Ordnance Survey (OS) chart. These references, 11 in total, were all found to be distributed evenly about a mean line orientated 079°(Grid) within the southern trail and were spread over a distance of 12 km. The distance of each reference from the line was measured in a direction parallel to the aircraft's track and all were found to be within 500 metres of the line, with 50% of them being within 250 metres of the line. This line is referred to as the datum line and is shown in Appendix B, Figure B-4.
22.214.171.124 Distribution of wreckage within the southern trail
North of the datum line and parallel to it were drawn a series of lines at distances of 250, 300, 600 and 900 metres respectively from the line, again measured in a direction parallel to the aircraft's track. The positions on the aircraft structure of specific items of wreckage, for which grid references were known with a high degree of confidence, within the bands formed between these lines, are shown in Appendix B, Figures B-10 to 13. In addition, a separate assessment of the grid references of tailplane and elevator wreckage established that these items were distributed evenly about the 600 metre line.
126.96.36.199 Area between trails
Immediately east of the crater, the southern trail converged with the northern trail such that, to an easterly distance of approximately 5 km, considerable wreckage existed which could have formed part of either trail. Further east, between 6 and 11 km from the crater, a small number of sections and fragments of the fin had fallen outside the southern boundary of the northern trail. Beyond this a large area existed between the trails in which there was no wreckage.
1.12.2 Examination of wreckage at CAD Longtown
The debris from all areas was recovered by the Royal Air Force to the Army Central Ammunition Depot Longtown, about 20 miles from Lockerbie. Approximately 90% of the hull wreckage was successfully recovered, identified, and laid out on the floor in a two-dimensional reconstruction [Appendix B, Figure B-14]. Baggage container material was incorporated into a full three-dimensional reconstruction. Items of wreckage added to the reconstructions was given a reference number and recorded on a computer database together with a brief description of the item and the location where it was found.
The reconstruction revealed the presence of damage consistent with an explosion on the lower fuselage left side in the forward cargo bay area. A small region of structure bounded approximately by frames 700 & 720 and stringers 38L & 40L, had clearly been shattered and blasted through by material exhausting directly from an explosion centred immediately inboard of this location. The material from this area, hereafter referred to as the 'shatter zone', was mostly reduced to very small fragments, only a few of which were recovered, including a strip of two skins [Appendix B, Figure B-15] forming part of the lap joint at the stringer 39L position.
Surrounding the shatter zone were a series of much larger panels of torn fuselage skin which formed a 'star-burst' fracture pattern around the shatter zone. Where these panels formed the boundary of the shatter zone, the metal in the immediate locality was ragged, heavily distorted, and the inner surfaces were pitted and sooted - rather as if a very large shotgun had been fired at the inner surface of the fuselage at close range. In contrast, the star-burst fractures, outside the boundary of the shatter zone, displayed evidence of more typical overload tearing, though some tears appeared to be rapid and, in the area below the missing panels, were multi-branched. These surrounding skin panels were moderately sooted in the regions adjacent to the shatter zone, but otherwise were lightly sooted or free of soot altogether. (Forensic analysis of the soot deposits on frame and skin material from this area confirmed the presence of explosive residues.) All of these skin panels had pulled away from the supporting structure and had been bent and torn in a manner which indicated that, as well as fracturing in the star burst pattern, they had also petalled outwards producing characteristic, tight curling of the sheet material.
Sections of frames 700 and 720 from the area of the explosion were also recovered and identified. Attached to frame 720 were the remnants of a section of the aluminium baggage container (side) guide rail, which was heavily distorted and displayed deep pitting together with very heavy sooting, indicating that it had been very close to the explosive charge. The pattern of distortion and damage on the frames and guide rail segment matched the overall pattern of damage observed on the skins.
The remainder of the structure forming the cargo deck and lower hull was, generally, more randomly distorted and did not display the clear indications of explosive processes which were evident on the skin panels and frames nearer the focus of the explosion. Nevertheless, the overall pattern of damage was consistent with the propagation of explosive pressure fronts away from the focal area inboard of the shatter zone. This was particularly evident in the fracture and bending characteristics of several of the fuselage frames ahead of, and behind station 700.
The whole of the two-dimensional fuselage reconstruction was examined for general evidence of the mode of disintegration and for signs of localised damage, including overpressure damage and pre-existing damage such as corrosion or fatigue. There was some evidence of corrosion and dis-bonding at the cold-bond lap joints in the fuselage. However, the corrosion was relatively light and would not have compromised significantly the static strength of the airframe. Certainly, there was no evidence to suggest that corrosion had affected the mode of disintegration, either in the area of the explosion or at areas more remote. Similarly, there were no indications of fatigue damage except for one very small region of fatigue, involving a single crack less than 3 inches long, which was remote from the bomb location. This crack was not in a critical area and had not coincided with a fracture path.
No evidence of overpressure fracture or distortion was found at the rear pressure bulkhead. Some suggestion of 'quilting' or 'pillowing' of skin panels between stringers and frames, indicative of localised overpressure, was evident on the skin panels attached to the larger segments of lower fuselage wreckage aft of the blast area. In addition, the mode of failure of the butt joint at station 520 suggested that there had been a rapid overpressure load in this area, causing the fastener heads to 'pop' in the region of stringers 13L to 16L, rather than producing shear in the fasteners. Further evidence of localised overpressure damage remote from the source of the explosion was found during the full three-dimensional reconstruction, detailed later in paragraph 188.8.131.52.
An attempt was made to analyse the fractures, to
determine the direction and sequence of failure as the fractures propagated
away from the region of the explosion. It was found that the directions
of most of the fractures close to the explosion could be determined from
an analysis of the fracture surfaces and other features, such as rivet
and rivet hole distortions. However, it was apparent that beyond the boundary
of the petalled region, the disintegration process had involved multiple
fractures taking place simultaneously - extremely complex parallel processes
which made the sequencing of events not amenable to conventional analysis.
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184.108.40.206 Wing structure and adjacent fuselage area
On completion of the initial layout at Longtown it became evident that, in the area from station 1000 to approximately station 1240 the only identifiable fuselage structure consisted of elements of fuselage skin, stringers and frames from above the cabin window belts. The wreckage from in and around the crater was therefore sifted to establish more accurately what sections of the aircraft had produced the crater. All of the material was highly fragmented, but it was confirmed that the material comprised mostly wing structure, with a few fragments of fuselage sidewall and passenger seats. The badly burnt state of these fragments made it clear that they were recovered from the area of the main impact crater, the only scene of significant ground fire. Amongst these items a number of cabin window forgings were recovered with sections of thick horizontal panelling attached having a length equivalent to the normal window spacing/frame pitch. This arrangement, with skins of this thickness, is unique to the area from station 1100 to 1260. It is therefore reasonable to assume that these fragments formed parts of the missing cabin sides from station 1000 to station 1260, which must have remained attached to the wing centre section at the time of its impact. Because of the high degree of fragmentation and the relative insignificance of the wing in terms of the overall explosive damage pattern, a reconstruction of the wing material was not undertaken. The sections of the aircraft which went into the crater are colour coded grey in Appendix B, Figures B-5 to B-8.
220.127.116.11 Fin and aft section of fuselage
Examination of the structure of the fin revealed evidence of in-flight damage to the leading edge caused by the impact of structure or cabin contents. This damage was not severe or extensive and the general break-up of the fin did not suggest either a single readily defined loading direction, or break-up due to the effects of leading edge impact. A few items of fin debris were found between the northern and southern trails.
A number of sections of fuselage frame found in the northern trail exhibited evidence of plastic deformation of skin attachment cleats and tensile overload failure of the attachment rivets. This damage was consistent with that which would occur if the skin had been locally subjected to a high loading in a direction normal to its plane. Although this was suggestive of an internal overpressure condition, the rear fuselage revealed no other evidence to support this possibility. Examination of areas of the forward fuselage known to have been subjected to high blast overpressures revealed no comparable evidence of plastic deformation in the skin attachment cleats or rivets, most skin attachment failures appearing to have been rapid.
Calculations made on the effects of internal pressure generated by an open ended fuselage descending at the highest speed likely to have been experienced revealed that this could not generate an internal pressure approaching that necessary to cause failure in an intact cabin structure.
18.104.22.168 Baggage containers
During the wreckage recovery operation it became apparent that some items, identified as parts of baggage containers, exhibited damage consistent with being close to a detonating high explosive. It was therefore decided to segregate identifiable container parts and reconstruct any that showed evidence of explosive damage. It was evident, from the main wreckage layout, that the explosion had occurred in the forward cargo hold and, although all baggage container wreckage was examined, only items from this area which showed the relevant characteristics were considered for the reconstruction. Discrimination between forward and rear cargo hold containers was relatively straightforward as the rear cargo hold wreckage was almost entirely confined to Lockerbie, whilst that from the forward hold was scattered along the southern wreckage trail.
All immediately identifiable parts of the forward cargo containers were segregated into areas designated by their serial numbers and items not identified at that stage were collected into piles of similar parts for later assessment. As a result of this, two adjacent containers, one of metal construction the other fibreglass, were identified as exhibiting damage likely to have been caused by the explosion. Those parts which could be positively identified as being from these two containers were assembled onto one of three simple wooden frameworks, one each for the floor and superstructure of the metal container and one for the superstructure of the fibreglass container. From this it was positively determined that the explosion had occurred within the metal container (serial number AVE 4041 PA), the direct effects of this being evident also on the forward face of the adjacent fibreglass container (serial number AVN 7511 PA) and on the local airframe on the left side of the aircraft in the region of station 700. It was therefore confirmed that this metal container had been loaded in position 14L in agreement with the aircraft loading records. While this work was in progress a buckled section of the metal container skin was found by an AAIB Inspector to contain, trapped within its folds, an item which was subsequently identified by forensic scientists at the Royal Armaments Research and Development Establishment (RARDE) as belonging to a specific type of radio-cassette player and that this had been fitted with an improvised explosive device (IED).
The reconstruction of these containers and their relationship to the aircraft structure is described in detail in Appendix F. Examination of all other components of the remaining containers revealed only damage consistent with ejection into the high speed slipstream and/or ground impact, and that only one device had detonated within the containers on board the aircraft.
1.12.3 Fuselage three-dimensional reconstruction
22.214.171.124 The reconstruction
The two-dimensional reconstruction successfully established that there had been an explosion in the forward hold; its location was established and the general damage characteristics in the vicinity of the explosion were determined. However, the mechanisms by which the failure process developed from local damage in the immediate vicinity of the explosion to the complete structural break-up and separation of the whole forward section of the fuselage, could not be adequately investigated without recourse to a more elaborate reconstruction.
To facilitate this additional work, wreckage forming a 65 foot section of the fuselage (approximately 30 feet each side of the explosion) was transported to AAIB Farnborough, where it was attached to a specially designed framework to form a fully three-dimensional reconstruction [Appendix B, Figures B-16 and B-17] of the complete fuselage between stations 360 & 1000 (from the separated nose section back to the wing cut out). The support framework was designed to provide full and free access to all parts of the structure, both internally and externally. Because of height constraints, the reconstruction was carried out in two parts, with the structure divided along a horizontal line at approximately the upper cabin floor level. The previously reconstructed containers were also transported to AAIB Farnborough to allow correlation of evidence with, and partial incorporation into, the fuselage reconstruction.
Structure and skin panels were attached to the supporting framework by their last point of attachment, to provide a better appreciation of the modes and direction of curling, distortion, and ultimate separation. Thus, the panels of skin which had petalled back from the shatter zone were attached at their outer edges, so as to identify the bending modes of the panels, the extent of the petalled region, and also the size of the resulting aperture in the hull. In areas more remote from the explosion, the fracture and tear directions were used together with distortion and curling directions to determine the mode of separation, and thus the most appropriate point of attachment to the reconstruction. Cabin floor beam segments were supported on a steel mesh grid and a plot of the beam fractures is shown at Appendix B, Figure B-18.
The cargo container base elements were separated from the rest of the container reconstruction and transferred to the main wreckage reconstruction, where the re-assembled container base was positioned precisely onto the cargo deck. To assist in the correlation of the initial shatter zone and petalled-out regions with the position of the explosive device, the boundaries of the skin panel fractures were marked on a transparent plastic panel which was then attached to the reconstruction to provide a transparent pseudo-skin showing the positions of the skin tear lines. This provided a clear visual indication of the relationship between the skin panel fractures and the explosive damage to the container base, thus providing a more accurate indication of the location of the explosive device.
126.96.36.199 Summary of explosive features evident
The three-dimensional reconstruction provided additional information about the region of tearing and petalling around the shatter zone. It also identified a number of other regions of structural damage, remote from the explosion, which were clearly associated with severe and rapidly applied pressure loads acting normal to the skin's internal surface. These were sufficiently sharp-edged to pre-empt the resolution of pressure induced loads into membrane tension stresses in the skin: instead, the effect was as though these areas of skin had been struck a severe 'pressure blow' from within the hull.
The two types of damage, i.e. the direct blast/tearing/petalling damage and the quite separate areas of 'pressure blow' damage at remote sites were evidently caused by separate mechanisms, though it was equally clear that each was caused by explosive processes, rather than more general disintegration.
The region of petalling was bounded (approximately) by frames 680 and 740, and extended from just below the window belt down nearly to the keel of the aircraft [Appendix B, Figure B-19, region A]. The resulting aperture measured approximately 17 feet by 5 feet. Three major fractures had propagated beyond the boundary of the petalled zone, clearly driven by a combination of hull pressurisation loading and the relatively long term (secondary) pressure pulse from the explosion. These fractures ran as follows:
|(i)||rearwards and downward in a stepped fashion, joining the stringer 38L lap joint at around station 840, running aft along stringer 38L to around station 920, then stepping down to stringer 39L and running aft to terminate at the wing box cut-out [Appendix B, Figure B-19, fracture 1].|
|(ii)||downwards and forward to join the stringer 44L lap joint, then running forward along stringer 44L as far as station 480 [Appendix B, Figure B-19, fracture 2].|
|(iii)||downwards and rearward, joining the butt line at station 740 to run under the fuselage and up the right side to a position approximately 18 inches above the cabin floor level [Appendix B, Figures B-19 and B-20, fracture 3].|
Regions of skin separation remote from the site of the explosion were evident in a number of areas. These principally were:
|(i)||A large section of upper fuselage skin extending from station 500 back to station 760, and from around stringers 15/19L up as far as stringer 5L [Appendix B, Figures B-19 and B-20, region B], and probably extending further up over the crown. This panel had separated initially at its lower forward edge as a result of a pressure blow type of impulse loading, which had popped the heads from the rivets at the butt joint on frame 500 and lifted the skin flap out into the airflow. The remainder of the panel had then torn away rearwards in the airflow.|
|A region of 'quilting' or 'pillowing', i.e. spherical bulging of skin panels between frames and stringers, was evident on these panels in the region between station 560 and 680, just below the level of the upper deck floor, indicative of high internal pressurisation loading [Appendix B, Figure B-19, region C].|
|(ii)||A smaller section of skin between stations 500 and 580, bounded by stringers 27L and 34L [Appendix B, Figure B-19, region D], had also been 'blown' outwards at its forward edge and torn off the structure rearwards. A characteristic curling of the panel was evident, consistent with rapid, energetic separation from the structure.|
|(iii)||A section of thick belly skin extending from station 560, stringers 40R to 44R, and tapering back to a point at stringer 45R/station720 [Appendix B, Figure B-19 and B-20, region E], had separated from the structure as a result of a very heavy 'pressure blow' load at its forward end which had popped the heads off a large number of substantial skin fasteners. The panel had then torn away rearwards from the structure, curling up tightly onto itself as it did so - indicating that considerable excess energy was involved in the separation process (over and above that needed simply to separate the skin material from its supporting structure).|
|(iv)||A panel of skin on the right side of the aircraft, roughly opposite the explosion, had been torn off the frames, beginning at the top edge of the panel situated just below the window belt and tearing downwards towards the belly [Appendix B, Figure B-20, region F]. This panel was curled downwards in a manner which suggested significant excess energy.|
The cabin floor structure was badly disrupted, particularly in the general area above the explosion, where the floor beams had suffered localised upward loading sufficient to fracture them, and the floor panels were missing. Elsewhere, floor beam damage was mainly limited to fractures at the outer ends of the beams and at the centreline, leaving sections of separated floor structure comprising a number of half beams joined together by the Nomex honeycomb floor panels.
188.8.131.52 General damage features not directly associated with explosive forces.
A number of features appeared to be a part of the general structural break-up which followed on from the explosive damage, rather than being a part of the explosive damage process itself. This general break-up was complex and, to a certain extent, random. However, analysis of the fractures, surface scores, paint smears and other features enabled a number of discreet elements of the break-up process to be identified. These elements are summarised below.
|(i)||Buckling of the window belts on both sides of the aircraft was evident between stations 660 and 800. That on the left side appeared to be the result of in-plane bending in a nose up sense, followed by fracture. The belt on the right side had a large radius curve suggesting lateral deflection of the fuselage possibly accompanied by some longitudinal compression. This terminated in a peeling failure of the riveted joint at station 800.|
|(ii)||On the left side three fractures, apparently resulting from in-plane bending/buckling distortion, had traversed the window belt [Appendix B, Figure B-21, detail G]. Of these, the forward two had broken through the window apertures and the aft fracture had exploited a rivet line at the region of reinforcement just forward of the L2 door aperture. On the right side, the window belt had peeled rearwards, after buckling had occurred, separating from the rest of the fuselage, following rivet failure, at the forward edge of the R2 door aperture.|
|(iii)||All crown skins forward of frame 840 were badly distorted and a number of pieces were missing. It was clearly evident that the skin sections from this region had struck the empennage and/or other structure following separation.|
|(iv)||The fuselage left side lower lobe from station 740 back to the wing box cut-out, and from the window level down to the cargo deck floor (the fracture line along stringer 38L), had peeled outwards, upwards and rearwards - separating from the rest of the fuselage at the window belt. The whole of this separated section had then continued to slide upwards and rearwards, over the fuselage, before being carried back in the slipstream and colliding with the outer leading edge of the right horizontal stabiliser, completely disrupting the outer half. A fragment of horizontal stabiliser spar cap was found embedded in the fuselage structure adjacent to the two vent valves, just below, and forward of, the L2 door [Appendix B, Figure B-22].|
|(v)||A large, clear, imprint of semi-eliptical form was apparent on the lower right side at station 360 which had evidently been caused by the separating forward fuselage section striking the No 3 engine as it swung rearwards and to the right (confirmed by No 3 engine fan cowl damage).|
The tailplane structural design took the form of a forward and an aft torque box. The forward box was constructed from light gauge aluminium alloy sheet skins, supported by closely pitched, light gauge nose ribs but without lateral stringers. The aft torque box incorporated heavy gauge skin/stringer panels with more widely spaced ribs. The front spar web was of light gauge material. Leading edge impacts inflicted by debris would therefore have had the capacity to reduce the tailplane's structural integrity by passing through the light gauge skins and spar web into the interior of the aft torque box, damaging the shear connection between top and bottom skins in the process and thereby both removing the bending strength of the box and opening up the weakened structure to the direct effects of the airflow.
Examination of the rebuilt tailplane structure at AAIB Farnborough left little doubt that it had been destroyed by debris striking its leading edges. In addition, the presence on the skins of smear marks indicated that some unidentified soft debris had contacted those surfaces whilst moving with both longitudinal and lateral velocity components relative to the aircraft.
The reconstructed left tailplane [Appendix B, Figure B-23] showed evidence that disruption of the inboard leading edge, followed respectively by the forward torque box, front spar web and main torque box, occurred as a result of frontal impact by the base of a baggage container. Further outboard, a compact object appeared to have struck the underside of the leading edge and penetrated to the aft torque box. In both cases, the loss of the shear web of the front spar appeared to have permitted local bending failure of the remaining main torque box structure in a tip downwards sense, consistent with the normal load direction. For both events to have occurred it would be reasonable to assume that the outboard damage preceded that occurring inboard.
The right tailplane exhibited massive leading edge
impact damage on the outboard portion which also appeared to have progressed
to disruption of the aft torsion box. A fragment of right tailplane spar
cap was found embedded in the fuselage structure adjacent to the two vent
valves, just below, and forward of, the L2 door and it is clear that this
area of forward left fuselage had travelled over the top of the aircraft
and contributed to the destruction of the outboard right tailplane.
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1.12.4 Examination of engines
All four engines had struck the ground in Lockerbie with considerable velocity and therefore sustained major damage, in particular to most of the fan blades. The No 3 engine had fallen 1,100 metres north of the other three engines, striking the ground on its rear face, penetrating a road surface and coming to rest without any further change of orientation i.e. with the front face remaining uppermost. The intake area contained a number of loose items originating from within the cabin or baggage hold. It was not possible initially to determine whether any of the general damage to any of the engine fans or the ingestion noted in No 3 engine intake occurred whilst the relevant engines were delivering power or at a later stage.
Numbers 1, 2 and 3 engines were taken to British Airways Engine Overhaul Limited for detailed examination under AAIB supervision in conjunction with a specialist from the Pratt and Whitney Engine Company. During this examination the following points were noted:
|(i)||No 2 engine (situated closest to the site of the explosion) had evidence of blade "shingling" in the area of the shrouds consistent with the results of major airflow disturbance whilst delivering power. (This effect is produced when random bending and torsional deflection occurs, permitting the mid-span shrouds to disengage and repeatedly strike the adjacent aerofoil surfaces of the blades). The interior of the air intake contained paint smears and other evidence suggesting the passage of items of debris. One such item of significance was a clear indentation produced by a length of cable of diameter and strand size similar to that typically attached to the closure curtains on the baggage containers.|
|(ii)||No 3 engine, identified on site as containing ingested debris from within the aircraft, nonetheless had no evidence of the type of shingling seen on the blades of No 2 engine. Such evidence is usually unmistakable and its absence is a clear indication that No 3 engine did not suffer a major intake airflow disturbance whilst delivering significant power. The intake structure was found to have been crushed longitudinally by an impact on the front face although, as stated earlier, it had struck the ground on its rear face whilst falling vertically.|
|(iii)||All 3 engines had evidence of blade tip rubs on the fan cases having a combination of circumference and depth greater than hitherto seen on any investigation witnessed on Boeing 747 aircraft by the Pratt and Whitney specialists. Subsequent examination of No 4 engine confirmed that it had a similar deep, large circumference tip rub. These tip-rubs on the four engines were centred at slightly different clock positions around their respective fan cases.|
Pratt and Whitney also advised that:
|(i)||Airflow disruption such as that presumed to have caused the shingling observed on No 2 engine fan blades was almost invariably the result of damage to the fan blade aerofoils, resulting from ingestion or blade failure.|
|(ii)||Tip rubs of a depth and circumference noted on all four engines could be expected to reduce the fan rotational energy on each to a negligible value within approximately 5 seconds.|
|(iii)||Airflow disruption sufficient to cause the extent of shingling noted on the fan blades of No 2 engine would also reduce the rotational fan energy to a negligible value within approximately 5 seconds.|
1.13 Medical and pathological information
The results of the post mortem examination of the victims indicated that the majority had experienced severe multiple injuries at different stages, consistent with the in-flight disintegration of the aircraft and ground impact. There was no pathological indication of an in-flight fire and no evidence that any of the victims had been injured by shrapnel from the explosion. There was also no evidence which unequivocally indicated that passengers or cabin crew had been killed or injured by the effects of a blast. Although it is probable that those passengers seated in the immediate vicinity of the explosion would have suffered some injury as a result of blast, this would have been of a secondary or tertiary nature.
Of the casualties from the aircraft, the majority were found in areas which indicated that they had been thrown from the fuselage during the disintegration. Although the pattern of distribution of bodies on the ground was not clear cut there was some correlation with seat allocation which suggested that the forward part of the aircraft had broken away from the rear early in the disintegration process. The bodies of 10 passengers were not recovered and of these, 8 had been allocated seats in rows 23 to 28 positioned over the wing at the front of the economy section. The fragmented remains of 13 passengers who had been allocated seats around the eight missing persons were found in or near the crater formed by the wing. Whilst there is no unequivocal proof that the missing people suffered the same fate, it would seem from the pattern that the missing passengers remained attached to the wing structure until impact.
Of the several large pieces of aircraft wreckage which fell in the town of Lockerbie, one was seen to have the appearance of a ball of fire with a trail of flame. Its final path indicated that this was the No 3 engine, which embedded itself in a road in the north-east part of the town. A small post impact fire posed no hazard to adjacent property and was later extinguished with water from a hosereel. The three remaining engines landed in the Netherplace area of the town. One severed a water main and the other two, although initially on fire, were no risk to persons or property and the fires were soon extinguished.
A large, dark, delta shaped object was seen to fall at about the same time in the Sherwood area of the town. It was not on fire while in the air, however, a fireball several hundred feet across followed the impact. It was of relatively short duration and large amounts of debris were thrown into the air, the lighter particles being carried several miles downwind, while larger pieces of burning debris caused further fires, including a major one at the Townfoot Garage, up to 350 metres from the source. It was determined that the major part of both wings, which included the aircraft fuel tanks, had formed the crater. A gas main had also been ruptured during the impact.
At 19.04 hrs the Dumfries Fire Brigade Control received a call from a member of the public which indicated that there had been a "huge boiler explosion" at Westacres, Lockerbie, however, subsequent calls soon made it clear that it was an aircraft which had crashed. At 19.07 hrs the first appliances were mobile and at 1910 hrs one was in attendance in the Rosebank area. Multiple fires were identified and it soon became apparent that a major disaster had occurred in the town and the Fire Brigade Major Incident Plan was implemented. During the initial phase 15 pumping appliances from various brigades were deployed but this number was ultimately increased to 20.
At 22.09 hrs the Firemaster made an assessment of the situation. He reported that there was a series of fires over an area of the town centre extending 1› by ¤ mile. The main concentration of the fire was in the southwest of the town around Sherwood Park and Sherwood Crescent. Appliances were in attendance at other fires in the town, particularly in Park Place and Rosebank Crescent. Water and electricity supplies were interrupted and water had to be brought into the town.
By 02.22 hrs on 22 December, all main seats of fire
had been extinguished and the firemen were involved in turning over and
damping down. At 04.42 hrs small fires were still occurring but had been
confined to the Sherwood Crescent area.
1.15 Survival aspects
The accident was not survivable.
1.15.2 Emergency services
A chronology of initial responses by the emergency services is listed below:-
|19.03 hrs||Radio message from Police patrol in Lockerbie to Dumfries and Galloway Constabulary reporting an aircraft crash at Lockerbie.|
|19.04 hrs||Emergency call to Dumfries and Galloway Fire Brigade.|
|19.37 hrs||First ambulances leave for Dumfries and Galloway Royal Infirmary with injured town residents. (2- serious; 3- minor)|
|19.40 hrs||Sherwood Park and Sherwood Crescent residents evacuated to Lockerbie Town Hall.|
|20.25 hrs||Nose section of N739PA discovered at Tundergarth (approximately 4 km east of Lockerbie).|
During the next few days a major emergency operation was mounted using the guidelines of the Dumfries and Galloway Regional Peacetime Emergency Plan. The Dumfries and Galloway Constabulary was reinforced by contingents from Strathclyde and Lothian & Borders Constabularies. Resources from HM Forces were made available and this support was subsequently authorised by the Ministry of Defence as Military Aid to the Civil Power. It included the provision of military personnel and a number of helicopters used mainly in the search for and recovery of aircraft wreckage. It was apparent at an early stage that there were no survivors from the aircraft and the search and recovery of bodies was mainly a Police task with military assistance.
Many other agencies were involved in the provision
of welfare and support services for the residents of Lockerbie, relatives
of the aircraft's occupants and personnel involved in the emergency operation.
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1.16 Tests and research
An explosive detonation within a fuselage, in reasonably close proximity to the skin, will produce a high intensity spherically propagating shock wave which will expand outwards from the centre of detonation. On reaching the inner surface of the fuselage skin, energy will partially be absorbed in shattering, deforming and accelerating the skin and stringer material in its path. Much of the remaining energy will be transmitted, as a shock wave, through the skin and into the atmosphere but a significant amount of energy will be returned as a reflected shock wave, which will travel back into the fuselage interior where it will interact with the incident shock to produce Mach stem shocks - re-combination shock waves which can have pressures and velocities of propagation greater than the incident shock.
The Mach stem phenomenon is significant because it
gives rise (for relatively small charge sizes) to a geometric limitation
on the area of skin material which the incident shock wave can shatter,
irrespective of charge size, thus providing a means of calculating the
standoff distance of the explosive charge from the fuselage skin. Calculations
suggest that a charge standoff distance of aproximately 25 inches would
result in a shattered region approximately 18 to 20 inches in diameter,
comparable to the size of the shattered region evident in the wreckage.
This aspect is covered in greater detail in [Appendix G].
1.17 Additional information
1.17.1 Recorded radar information
Recorded radar information on the aircraft was available from 4 radar sites. Initial analysis consisted of viewing the recorded information as it was shown to the controller on the radar screen from which it was clear that the flight had progressed in a normal manner until secondary surveillance radar (SSR) was lost.
The detailed analysis of the radar information concentrated on the break-up of the aircraft. The Royal Signals and Radar Establishment (RSRE) corrected the radar returns for fixed errors and converted the SSR returns to latitude and longitude so that an accurate time and position for the aircraft could be determined. The last secondary return from the aircraft was recorded at 19.02:46.9 hrs, identifying N739PA at Flight Level 310, and at the next radar return there is no SSR data, only 4 primary returns. It was concluded that the aircraft was, by this time, no longer a single return and, considering the approximately 1 nautical mile spread of returns across track, that items had been ejected at high speed probably to both right and left of the aircraft.
Each rotation of the radar head thereafter showed the number of returns increasing, with those first identified across track having slowed down very quickly and followed a track along the prevailing wind line. The radar evidence then indicated that a further break-up of the aircraft had occurred and formed a parallel wreckage trail to the north of the first. From the absence of any returns travelling along track it was concluded that the main wreckage was travelling almost vertically downwards for much of the time.
A detailed analysis of the recorded radar information, together with the radar, ATC and seismic recordings is contained in Appendix C.
1.17.2 Seismic data
The British Geological Survey has a number of seismic monitoring stations in Southern Scotland. Stations close to Lockerbie recorded a seismic event measuring 1.6 on the Richter scale and, with appropriate corrections for the times of the waves to reach the sensors, it was established that this occurred at 19.03:36.5 hrs ±1 second. A further check was made by triangulation techniques from the information recorded by the various sensors.
An analysis of the seismic recording, together with the radar, ATC and radar information is contained in Appendix C.
1.17.3 Trajectory analysis
A detailed trajectory analysis was carried out by Cranfield Institute of Technology in an effort to provide a sequence for the aircraft disintegration. This analysis comprised several separate processes, including individual trajectory calculations for a limited number of key items of wreckage and mathematical modelling of trajectory paths adopted by a series of hypothetical items of wreckage encompassing the drag/weight spectrum of the actual wreckage.
The work carried out at Cranfield enabled the reasons for the two separate trails to be established. The narrow northern trail was shown to be created by debris released from the aircraft in a vertical dive between 19,000 and 9,000 feet overhead Lockerbie. The southern trail, longer and straight for most of its length, appeared to have been created by wreckage released during the initial disintegration at altitude whilst the aircraft was in level flight. Those items falling closest to Lockerbie would have been those with higher density which would travel a significant distance along track before losing all along-track velocity, whilst only drifting a small distance downwind, owing to the high speed of their descent. The most westerly items thus showed the greatest such effect. The southern trail therefore had curved boundaries at its western end with the curvature becoming progressively less to the east until the wreckage essentially fell in a straight band. Thus wreckage in the southern trail positioned well to the east could be assumed to have retained negligible velocity along aircraft track after separation and the along-track distribution could be used to establish an approximate sequence of initial disintegration.
The analysis calculated impact speeds of 120 kts for the nose section weighing approximately 17,500 lb and 260 kts for the engines and pylons which each weighed about 13,500 lb. Based on the best available data at the time, the analysis showed that the wing (approximately 100,000 lb of structure containing an estimated 200,000 lb of fuel) could have impacted at a speed, in theory, as high as 650 kts if it had 'flown' in a streamlined attitude such that the drag coefficient was minimal. However, because small variations of wing incidence (and various amounts of attached fuselage) could have resulted in significant increases in drag coefficient, the analysis also recognized that the final impact speed of the wing could have been lower.
1.17.4 Space debris re-entry
Four items of space debris were known to have re-entered
the Earth's atmosphere on 21 December 1988. Three of these items were fragments
of debris which would not have survived re-entry, although their burn up
in the upper atmosphere might have been visible from the Earth's surface.
The fourth item landed in the USSR at 09.50 hrs UTC.
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The airport security and criminal aspects of the destruction of Boeing 747 registration N739PA near Lockerbie on 21 December 1988 are the subjects of a separate investigation and are not covered in this report. This analysis discusses the technical aspects of the disintegration of the aircraft and considers possible ways of mitigating the effects of an explosion in the future.
2.2 Explosive destruction of the aircraft
The geographical position of the final secondary return at 19.02:46.9 hrs was calculated by RSRE to be OS Grid Reference 15257772, annotated Point A in Appendix B, Figure B-4, with an accuracy considered to be better than ±300 metres This return was received 3.1±1 seconds before the loud sound was recorded on the CVR at 19.02:50 hrs. By projecting from this position along the track of 321°(Grid) for 3.1±1 seconds at the groundspeed of 434 kts, the position of the aircraft was calculated to be OS Grid Reference 14827826, annotated Point B in Appendix B, Figure B-4, within an accuracy of ±525 metres. Based on the evidence of recorded data only, Point B therefore represents the geographical position of the aircraft at the moment the loud sound was recorded on the CVR.
The datum line, discussed at paragraph 184.108.40.206, was derived from a detailed analysis of the distribution of specific items of wreckage, including those exhibiting positive evidence of a detonating high performance plastic explosive. The scatter of these items about the datum line may have been due partly to velocities imparted by the force of the detonating explosive and partly by the difficulty experienced in pinpointing the location of the wreckage accurately in relatively featureless terrain and poor visibility. However, the random nature of the scatter created by these two effects would have tended to counteract one another, and a major error in any one of the eleven grid references would have had little overall effect on the whole line. There is, therefore, good reason to have confidence in the validity of the datum line.
The items used to define the datum line, included those exhibiting positive evidence of a detonating high performance plastic explosive, would have been the first pieces to have been released from the aircraft. The datum line was projected westwards until it intersected the known radar track of the aircraft in order to derive the position of the aircraft along track at which the explosive items were released and therefore the position at which the IED had detonated. This position was OS grid reference 146786 and is annotated Point C in Appendix B, Figure B-4. Point C was well within the circle of accuracy (±525 metres) of the position at which the loud noise was heard on the CVR (Point B). There can, therefore, be no doubt that the loud noise on the CVR was directly associated with the detonation of the IED and that this explosion initiated the disintegration process and directly caused the loss of the aircraft.
2.3 Flight recorders
2.3.1 Digital flight data recordings
A working group of the European Organisation for Civil Aviation Electronics (EUROCAE) was, during the period of the investigation, formulating new standards (Minimum Operational Performance Requirement for Flight Data Recorder Systems, Ref:- ED55) for future generation flight recorders which would have permitted delays between parameter input and recording (buffering) of up to ¤ second. These standards are intended to form the basis of new CAA specifications for flight recorders and may be adopted worldwide.
The analysis of the recording from the DFDR fitted to N739PA, which is detailed in Appendix C, showed that the recorded data simply stopped. Following careful examination and correlation of the various sources of recorded information, it was concluded that this occurred because the electrical power supply to the recorder had been interrupted at 19.02:50 hrs ±1 second. Only 17 bits of data were not recoverable (less that 23 milliseconds) and it was not possible to establish with any certainty if this data was from the accident flight or was old data from a previous recording.
The analysis of the final data recorded on the DFDR was possible because the system did not buffer the incoming data. Some existing recorders use a process whereby data is stored temporarily in a memory device (buffer) before recording. The data within this buffer is lost when power is removed from the recorder and in currently designed recorders this may mean that up to 1.2 seconds of final data contained within the buffer is lost. Due to the necessary processing of the signals prior to input to the recorder, additional delays of up to 300 milliseconds may be introduced. If the accident had occurred when the aircraft was over the sea, it is very probable that the relatively few small items of structure, luggage and clothing showing positive evidence of the detonation of an explosive device would not have been recovered. However, as flight recorders are fitted with underwater location beacons, there is a high probability that they would have been located and recovered. In such an event the final milliseconds of data contained on the DFDR could be vital to the successful determination of the cause of an accident whether due to an explosive device or other catastrophic failure. Whilst it may not be possible to reduce some of the delays external to the recorder, it is possible to reduce any data loss due to buffering of data within the data acquisition unit.
It is, therefore, recommended that manufacturers
of existing recorders which use buffering techniques give consideration
to making the buffers non-volatile, and hence recoverable after power loss.
Although the recommendation on this aspect, made to the EUROCAE working
group during the investigation, was incorporated into ED55, it is also
recommended that Airworthiness Authorities re-consider the concept of allowing
buffered data to be stored in a volatile memory.
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2.3.2 Cockpit voice recorders
The analysis of the cockpit voice recording, which is detailed in Appendix C, concluded that there were valid signals available to the CVR when it stopped at 19.02:50 hrs ±1 second because the power supply to the recorder was interrupted. It is not clear if the sound at the end of the recording is the result of the explosion or is from the break-up of the aircraft structure. The short period between the beginning of the event and the loss of electrical power suggests that the latter is more likely to be the case. In order to respond to events that result in the almost immediate loss of the aircraft's electrical power supply it was therefore recommended during the investigation that the regulatory authorities consider requiring CVR systems to contain a short duration (i.e. no greater than 1 minute) back-up power supply.
2.3.3 Detection of explosive occurrences
In the aftermath of the Air India Boeing 747 accident (AI 182) in the North Atlantic on 23 June 1985, RARDE were asked informally by AAIB to examine means of differentiating, by recording violent cabin pressure pulses, between the detonation of an explosive device within the cabin (positive pulse) and a catastrophic structural failure (negative pulse). Following the Lockerbie disaster it was considered that this work should be raised to a formal research project. Therefore, in February 1989, it was recommended that the Department of Transport fund a study to devise methods of recording violent positive and negative pressure pulses, preferably utilising the aircraft's flight recorder systems. This recommendation was accepted.
Preliminary results from the trials indicate that, if a suitable sensor can be developed, its output will need to be recorded in real time and therefore it may require wiring to the CVR installation. This will further strengthen the requirement for battery back up of the CVR electrical power supply.
2.4 IED position within the aircraft
From the detailed examination of the reconstructed luggage containers, discussed at paragraph 220.127.116.11 and in Appendix F, it was evident that the IED had been located within a metal container (serial number AVE 4041 PA), near its aft outboard quarter as shown in Appendix F, Figure F-13. It was also clear that the container was loaded in position 14L of the forward hold which placed the explosive charge approximately 25 inches inboard from the fuselage skin at frame 700. There was no evidence to indicate that there was more than one explosive charge.
2.5 Engine evidence
To produce the fan blade tip rub damage noted on all engines by means of airflow inclined to the axes of the nacelles would have required a marked nose down change of aircraft pitch attitude combined with a roll rate to the left while all of the engines were attached to the wing.
The shingling damage noted on the fan blades of No 2 engine can only be attributed to airflow disturbance caused by ingestion related fan blade damage occurring when substantial power was being delivered. This is readily explained by the fact that No 2 engine intake is positioned some 27 feet aft and 30 feet outboard of the site of the explosion and that the interior of the intake exhibited a number of prominent paint smears and general foreign object damage. This damage included evidence of a strike by a cable similar to that forming part of the closure curtain of a typical baggage container. It is inconceivable that an independent blade failure could have occurred in the short time frame of this event. By similar reasoning, the absence of such shingling damage on blades of No 3 engine was a reliable indication that it suffered no ingestion until well into the accident sequence.
The combination of the position of the explosive device and the forward speed of the aircraft was such that significant sized debris resulting from the explosion would have been available to be ingested by No 2 engine within milliseconds of the explosion. In view of the fact that the tip rub damage observed on the fan case of No 2 engine is of similar magnitude to that observed on the other three engines it is reasonable to deduce that a manoeuvre of the aircraft occurred before most of the energy of the No 2 engine fan was lost due to the effect of ingestion (seen only in this engine). Since this shingling effect could only readily be produced as a by-product of ingestion whilst delivering considerable power, it is reasonable to assume that this was also occurring before loss of major fan energy due to tip rubbing took place. Hence both phenomena must have been occurring simultaneously, or nearly so, to produce the effects observed and must have occupied a time frame of substantially less than 5 seconds. The onset of this time period would have been the time at which debris from the explosion first inflicted damage to fan blades in No 3 engine and, since the fan is only approximately 40 feet from the location of the explosive device, this would have been an insignificant time interval after the explosion.
It was therefore concluded from this evidence that the wing with all of the engines attached had achieved a marked nose down and left roll attitude change well within 5 seconds of the explosion.
2.6 Detachment of forward fuselage
Examination of the three major structural elements
either side of the region of station 800 on the right side of the fuselage
makes it clear that to produce the curvature of the window belt and peeling
of the riveted joint at the R2 door aperture requires the door pillar to
be securely in position and able to react longitudinal and lateral loads.
This in turn requires the large section of fuselage on the right side between
stations 760 and 1000 (incorporating the right half of the floor) to be
in position in order to locate the lower end of the door pillar. Thus both
these sections must have been in position until the section from station
560 to 800 (right side) had completed its deflection to the right and peeled
from the door pillar. Separation of the forward fuselage must thus have
been complete by the time all three items mentioned above had fallen free.
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2.7 Speed of initial disintegration
The distribution of wreckage in the bands between the datum line and the 250, 300, 600 and 900 metre lines was examined in detail. The positions of these items of structure on the aircraft are shown in Appendix B, Figures B-10 to B-13. It should be noted that the position on the ground of these items, although separated by small distances when measured in a direction along aircraft track, were distributed over large distances when measured along the wreckage trail. All were recovered from positions far enough to the east to be in that part of the southern trail which was sufficiently close, theoretically, to a straight line for any curvature effect to be neglected.
The wreckage found in each of the bands enabled an approximate sequence of break-up to be established. It was clear that as the distance travelled from the datum line increased, items of wreckage further from the station of the IED were encountered. The items shown on the diagram as falling on the 250 metre band also include those fragments of lower forward fuselage skin having evidence of explosive damage and presumed to have separated as a direct result of the blast. However, a few portions of the upper forward fuselage were also found within the 250 metre band, suggesting that these items had also separated as a result of the blast.
By the time the 300 metre line was reached much of the structure from the right side in the region of the explosive device had been shed. This included the area of window belt, referred to in paragraph 2.6 above, which gave clear indications that the forward structure had detached to the right and finally peeled away at station 800. It also included the areas of adjacent structure immediately to the rear of station 800 about which the forward structure would have had to pivot. By the time the 600 metre line was reached, there was clearly insufficient structure left to connect the forward fuselage with the remainder of the aircraft. Wreckage between the 600 and 900 metre lines consisted of structure still further from the site of the IED.
There is evidence that a manoeuvre occurred at the time of the explosion which would have produced a significant change of the aircraft's flight path, however, it is considered that the change in the horizontal velocity component in the first few seconds would not have been great. The original groundspeed of the aircraft was therefore used in conjunction with the distribution of wreckage in the successive bands to establish an approximate time sequence of break-up of the forward fuselage. Assuming the original ground speed of 434 Kts, the elapsed flight times from the datum to each of the parellel lines were calculated to be:
The separate assessment of the known grid references of tailplane and elevator wreckage in the southern trail revealed that those items were evenly distributed about the 600 metre line and therefore that most of the tailplane damage occurred after separation of the forward fuselage was complete.
2.8 The manoeuvre following the explosion
The engine evidence, timing and mode of disintegration of the fuselage and tailplane suggests that the latter did not sustain significant damage until the forward fuselage disintegration was well advanced and the pitch/roll manoeuvre was also well under way.
Examination of the three dimensional reconstruction makes it clear that both main and upper deck floors were disrupted by the explosion. Since pitch control cables are routed through the upper deck floor beams and the roll control cables through the main deck beams, there is a strong possibility that movement of the beams under explosive forces would have applied inputs to the control cables, thus operating control surfaces in both axes.
2.9 Secondary disintegration
The distribution of fin debris between the trails suggests that disintegration of the fin began shortly before the vertical descent was established. No single mode of failure was identified and the debris which had struck the leading edge had not caused major disruption. The considerable fragmentation of the thick panels of the aft torque box was also very different from that noted on the corresponding structure of the tailplanes. It was therefore concluded that the mode of failure was probably flutter.
The finding, in the northern trail, of a slide raft wrapped around a flap track fairing suggests that at a later stage of the disintegration the rear of the aircraft must have experienced a large angle of sideslip. The loss of the fin would have made this possible and also subjected the structure to large side loads. It is possible that such side loading would have assisted the disintegration of the rear fuselage and also have caused bending failure of the pylon attachments of the remaining three engines.
2.10 Impact speed of components
The trajectory analysis carried out by Cranfield Institute of Technology calculated impact speeds of 120 kts for the nose section, and 260 kts for the engines and pylons. These values were considered to be reliable because the drag coefficients could be estimated with a reasonable degree of confidence. Based on the best available data at the time, the analysis also showed that the wing could have impacted at a speed, in theory, as high as 650 kts if it had flown in a streamlined attitude such that the drag coefficient was minimal. However, it was also recognized that relatively small changes in the angle of incidence of the wing would have produced a significant increase in drag with a consequent reduction in impact speed. Refinement of timing information and radar data subsequent to the Cranfield analysis has enabled a revised estimate to be made of the mean speed of the wing during the descent.
The engine evidence indicated that there had been a large nose down attitude change of the aircraft early in the event. The Cranfield analysis also showed that the rear fuselage had disintegrated while essentially in a vertical descent between 19,000 and 9,000 feet over Lockerbie. Assuming that, following the explosion, the wing followed a straight line descending flight profile from 31,000 feet to 19,000 feet directly overhead Lockerbie and then descended vertically until impact, the wing would have travelled the minimum distance practicable. The ground distance between the geographical position at which the disintegration started (Figure B-4, Point B) and the crater made by the wing impact was 2997 ±525 metres (9833 ±1722 feet). The time interval between the explosion and the wing impact was established in Appendix C as 46.5 ±2 seconds. Based on the above times and distances the mean linear speed achieved by the wing would have been about 440 kts.
The impact location of Nos 1, 2, and 4 engines closely grouped in Lockerbie was consistent with their nearly vertical fall from a point above the town. If they had separated at about 19,000 feet and the wing had then flown as much as one mile away from the overhead position before tracking back to impact, the total flight path length of the wing would not have required it to have achieved a mean linear speed in excess of 500 kts.
Any speculation that the flight path of the wing could have been longer would have required it to have undergone manoeuvres at high speed in order to arrive at the 19,000 feet point. The manoeuvres involved would almost certainly have resulted in failure of the primary wing structure which, from distribution of wing debris, clearly did not occur. Alternatively the wing could have travelled more than one mile from Lockerbie after reaching the 19,000 feet point, but this was considered unlikely. It is therefore concluded that the mean speed of the wing during the descent was in the region of 440 to 500 kts.
2.11 Sequence of disintegration
Analysis of wreckage in each of the bands, taken in conjunction with the engine evidence and the three-dimensional reconstruction, suggests the following sequence of disintegration:
|(i)||The initial explosion triggered a sequence of events which effectively destroyed the structural integrity of the forward fuselage. Little more then remained between stations 560 and 760 (approximately) than the window belts and the cabin sidewall structure immediately above and below the windows, although much of the cargo-hold floor structure appears to have remained briefly attached to the aircraft. [Appendix B, Figure B-24]|
|(ii)||The main portion of the aircraft simultaneously entered a manoeuvre involving a marked nose down and left roll attitude change, probably as a result of inputs applied to the flying control cables by movement of structure.|
|(iii)||Failure of the left window belt then occurred, probably in the region of station 710, as a result of torsional and bending loads on the fuselage imparted by the manoeuvre (i.e. the movement of the forward fuselage relative to the remainder of the aircraft was an initial twisting motion to the right, accompanied by a nose up pitching deflection).|
|(iv)||The forward fuselage deflected to the right, pivoting about the starboard window belt, and then peeled away from the structure at station 800. During this process the lower nose section struck the No 3 engine intake causing the engine to detach from its pylon. This fuselage separation was apparently complete within 3 seconds of the explosion.|
|(v)||Structure and contents of the forward fuselage struck the tail surfaces contributing to the destruction of the outboard starboard tailplane and causing substantial damage to the port unit. This damage occurred approximately 600 metres track distance after the explosion and therefore appears to have happened after the fuselage separation was complete.|
|(vi)||Fuselage structure continued to break away from the aircraft and the separated forward fuselage section as they descended.|
|(vii)||The aircraft maintained a steepening descent path until it reached the vertical in the region of 19,000 feet approximately over the final impact point. Shortly before it did so the tail fin began to disintegrate.|
|(viii)||The mode of failure of the fin is not clear, however, flutter of its structure is suspected.|
|(ix)||Once established in the vertical dive, the fin torque box continued to disintegrate, possibly permitting the remainder of the aircraft to yaw sufficiently to cause side load separation of Nos 1, 2 and 4 engines, complete with their pylons.|
|(x)||Break-up of the rear fuselage occurred during the vertical descent, possibly as a result of loads induced by the yaw, leaving a section of cabin floor and baggage hold from approximately stations 1241 to 1920, together with 3 landing gear units, to fall into housing at Rosebank Terrace.|
|(xi)||The main wing structure struck the ground with a high yaw angle at Sherwood Crescent.|
2.12 Explosive mechanisms and the structural disintegration
The fracture and damage pattern analysis was mainly of an interpretive nature involving interlocking pieces of subtle evidence such as paint smears, fracture and rivet failure characteristics, and other complex features. In the interests of brevity, this analysis will not discuss the detailed interpretation of individual fractures or damage features. Instead, the broader 'damage picture' which emerged from the detailed work will be discussed in the context of the explosive mechanisms which might have produced the damage, with a view to identifying those features of greatest significance.
It is important to keep in mind that whilst the processes involved are considered and discussed separately, the timescales associated with shock wave propagation and the high velocity gas flows are very short compared with the structural response timescales. Consequently, material which was shattered or broken by the explosive forces would have remained in place for a sufficiently long time that the structure can be considered to have been intact throughout much of the period that these explosive propagation phenomena were taking place.
2.12.1 Direct blast effect
18.104.22.168 Shock wave propagation
The direct effect of the explosive detonation within the container was to produce a high intensity spherically propagating shock wave which expanded from the centre of detonation close to the side of the container, shattering part of the side and base of the container as it passed through into the gap between the container and the fuselage skin. In breaking out of the container, some internal reflection and Mach stem interaction would have occurred, but this would have been limited by the absorptive effect of the baggage inboard, above, and forward of the charge. The force of the explosion breaking out of the container would therefore have been directed downwards and rearwards.
The heavy container base was distorted and torn downwards, causing buckling of the adjoining section of frame 700, and the container sides were blasted through and torn, particularly in the aft lower corner. Some of the material in the direct path of the explosive pressure front was reduced to shrapnel sized pieces which were rapidly accelerated outwards behind the primary shock front. Because of the overhang of the container's sloping side, fragments from both the device itself and the container wall impacted the projecting external flange of the container base edge member, producing micro cratering and sooting. Metallurgical examination of the internal surfaces of these craters identified areas of melting and other features which were consistent only with the impact of very high energy particles produced by an explosion at close quarters. Analysis of material on the crater surfaces confirmed the presence of several elements and compounds foreign to the composition of the edge member, including material consistent with the composition of the sheet aluminium forming the sloping face of the container.
On reaching the inner surface of the fuselage skin, the incident shock wave energy would partially have been absorbed in shattering, deforming and accelerating the skin and stringer material in its path. Much of its energy would have been transmitted, as a shock wave, through the skin and into the atmosphere [Appendix B, Figure B-25], but a significant amount of energy would have been returned as a reflected shock wave, back into the cavity between the container and the fuselage skin where Mach stem shock waves would have been formed. Evidence of rapid shattering was found in a region approximately bounded by frames 700 & 720 and stringers 38L & 40L, together with the lap joint at 39L.
The shattered fuselage skin would have taken a significant time to move, relative to the timescales associated with the primary shock wave propagation. Clear evidence of soot and small impact craters were apparent on the internal surfaces of all fragments of container and structure from the shatter zone, confirming that the this material had not had time to move before it was hit by the cloud of shrapnel, unburnt explosive residues and sooty combustion products generated at the seat of the explosion.
Following immediately behind the primary shock wave, a secondary high pressure wave - partly caused by reflections off the baggage behind the explosive material but mainly by the general pressure rise caused by the chemical conversion of solid explosive material to high temperature gas - emerged from the container. The effect of this second pressure front, which would have been more sustained and spread over a much larger area, was to cause the fuselage skin to stretch and blister outwards before bursting and petalling back in a star-burst pattern, with rapidly running tear fractures propagating away from a focus at the shatter zone. The release of stored energy as the skin ruptured, combined with the outflow of high pressure gas through the aperture, produced a characteristic curling of the skin 'petals' - even against the slipstream. For the most part, the skins which petalled back in this manner were torn from the frames and stringers, but the frames and stringers themselves were also fractured and became separated from the rest of the structure, producing a very large jagged hole some 5 feet longitudinally by 17 feet circumferentially (upwards to a region just below the window belt and downwards virtually to the centre line).
From this large jagged hole, three of the fractures continued to propagate away from the hole instead of terminating at the boundary. One fracture propagated longitudinally rearwards as far as the wing cut-out and another forwards to station 480, creating a continuous longitudinal fracture some 43 feet in length. A third fracture propagated circumferentially downwards along frame 740, under the belly, and up the right side of the fuselage almost as far as the window belt - a distance of approximately 23 feet.
These extended fractures all involved tearing or related failure modes, sometimes exploiting rivet lines and tearing from rivet hole to rivet hole, in other areas tearing along the full skin section adjacent to rivet lines, but separate from them. Although the fractures had, in part, followed lap joints, the actual failure modes indicated that the joints themselves were not inherently weak, either as design features or in respect of corrosion or the conditions of the joints on this particular aircraft.
Note: The cold bond process carried out at manufacture on the lap joints had areas of disbonding prior to the accident. This disbonding is a known feature of early Boeing 747 aircraft which, by itself, does not detract from the structural integrity of the hull. The cold bond adhesive was used to improve the distribution of shear load across the joint, thus reducing shear transfer via the fasteners and improving the resistance of the joint to fatigue damage; the fasteners were designed to carry the full static loading requirements of the joint without any contribution from the adhesive. Thus, the loss of the cold bond integrity would only have been significant if it had resulted in the growth of fatigue cracks, or corrosion induced weaknesses, which had then been exploited by the explosive forces. No evidence of fatigue cracking was found in the bonded joints. Inter-surface corrosion was present on most lap joints but only one very small region of corrosion had resulted in significant material thinning; this was remote from the critical region and had not played any part in the break-up.
The cracks propagating upwards as part of the petalling process did not extend beyond the window line. The wreckage evidence suggests that the vertical fractures merged, effectively closing off the fracture path to produce a relatively clean bounding edge to the upper section of the otherwise jagged hole produced by the petalling process. There are at least two probable reasons for this. Firstly the petalling fractures above the shattered zone did not diverge, as they had tended to do elsewhere. Instead, it appears that a large skin panel separated and peeled upwards very rapidly producing tears at each side which ran upwards following almost parallel paths. However, there are indications that by the time the fractures had run several feet, the velocity of fracture had slowed sufficiently to allow the free (forward) edge of the skin panel to overtake the fracture fronts, as it flexed upwards, and forcibly strike the fuselage skin above, producing clear witness marks on both items. Such a tearing process, in which an approximately rectangular flap of skin is pulled upwards away from the main skin panel, is likely to result in the fractures merging. Secondly, this merging tendency would have been reinforced in this particular instance by the stiff window belt ahead of the fractures, which would have tended to turn the fractures towards the horizontal.
It appears that the presence of this initial ('clean') hole, together with the stiff window belt above, encouraged other more slowly running tears to break into it, rather than propagating outwards away from the main hole.
22.214.171.124 Critical crack considerations
The three very large tears extending beyond the boundary of the petalled region resulted in a critical reduction of fuselage structural integrity.
Calculations were carried out at the Royal Aerospace Establishment to determine whether these fractures, growing outwards from the boundary of the petalled hole, could have occurred purely as a result of normal differential pressure loading of the fuselage, or whether explosive forces were required in addition to the pressurisation loads.
Preliminary calculations of critical crack dimensions for a fuselage skin punctured by a 20 by 20 inches jagged hole indicated that unstable crack growth would not have occurred unless the skin stress had been substantially greater than the stress level due to normal pressurisation loads alone. It was therefore clear that explosive overpressure must have produced the gross enlargement of the initially small shattered hole in the hull. Furthermore, it was apparent from the degree of curling and petalling of the skin panels within the star-burst region that this overpressure had been relatively long term, compared with the shock wave overpressure which had produced the shatter zone. A more refined analysis of critical crack growth parameters was therefore carried out in which it was assumed that the long term explosive overpressure was produced by the chemical conversion of solid explosive material into high temperature gas.
An outline of the fracture propagation analysis is given at Appendix D. This analysis, using theoretical fracture mechanics, showed that, after the incident shock wave had produced the shatter zone, significant explosive overpressure loads were needed to drive the star-burst fractures out to the boundary of the petalled skin zone. Thereafter, residual gas overpressure combined with fuselage pressurisation loads were sufficient to produce the two major longitudinal cracks and a single major circumferential crack, extending from the window belt down to beyond the keel centreline.
126.96.36.199 Damage to the cabin floor structure
The floor beams in the region immediately above the baggage container in which the explosive had detonated were extensively broken, displaying clear indications of overload failure due to buckling caused by localised upward loading of the floor structure.
No direct evidence of bruising was found on the top panel of the container. It therefore appears that the container did not itself impact the floor beams, but instead the floor immediately above the container was broken through as a result of explosive overpressure as gases emerged from the ruptured container and loaded the floor panels. Data on floor strengths, provided by Boeing, indicated that the cabin floor (with the CRAF modification) would fail at a uniform static differential pressure of between 3.5 and 3.9 psi (high pressure below the cabin floor), and that the floor panel to floor beam attachments would not fail before the floor beams. Whilst there is no direct evidence of the pressure loading on the floor structure immediately following detonation, there can be no doubt that in the region of station 700 it would have exceeded the ultimate failure load by a large margin.
2.12.2 Indirect explosive damage (damage at remote sites)
All of the damage considered in the foregoing analysis, and the mechanisms giving rise to that damage, resulted from the direct impact of explosive shock waves and/or the short-term explosive overpressure on structure close to the source of the explosion. However, there were several regions of skin separation at sites remote from the explosion (see para 188.8.131.52) which were much more difficult to understand. These remote sites formed islands of indirect explosive damage separated from the direct damage by a sea of more generalised structural failure characterised by the progressive aerodynamic break-up of the weakened forward fuselage. All of these remote damage sites were consistent with the impact of very localised pressure impulses on the internal surfaces of the hull -effectively high energy 'pressure blows' against the inner surfaces produced by explosive shock waves and/or high pressure gas flows travelling through the interior spaces of the hull.
The propagation of explosive shock waves and supersonic gas flows within multiple, interlinking, cavities having indeterminate energy absorption and reflection properties, and ill-defined structural response, is extremely complex. Work has been initiated in an attempt to produce a three-dimensional computer analysis of the shock wave and supersonic flow propagation inside the fuselage, but full theoretical analysis is beyond present resources.
Because of the complexity of the problem, the following analysis will be restricted to a qualitative consideration of the processes which were likely to have taken place. Whilst such an approach is necessarily limited, it has identified a number of propagation mechanisms which appear to have been of fundamental importance to the break-up of Flight PA103, and which are likely to be critical in any future incident involving the detonation of high explosive inside an aircraft hull.
184.108.40.206 Shock wave propagation through internal cavities
When Mach stem shocks are produced not only are the shock pressures very high but they propagate at very high velocity parallel to the reflecting surface. In the context of the lower fuselage structure in the region of Mach stem formation, it can readily be seen that the Mach stem will be perfectly orientated to enter the narrow cavity formed between the outer skin and the cargo liner/containers, bounded by the fuselage frames [Appendix B, Figure B-25]. This cavity enables the Mach stem shock wave to propagate, without causing damage to the walls (due to the relatively low pressure where the Mach stem sweeps their surface), and reach regions of the fuselage remote from the source of the explosion. Furthermore, energy losses in the cavity are likely to be less than would occur in the 'free' propagation case, resulting in the efficient transmission of explosive energy. The cavity would tend to act like a 'shock tube', used for high speed aerodynamic research, confining the shock wave and keeping it running along the cavity axis, with losses being limited to kinetic heating due to friction at the walls.
Paragraph 1.6.3 contains a general description of the structural arrangements in the area of the cargo hold. Before proceeding further and considering how the shock waves might have propagated through this network of cavities, it should be pointed out that the timescale associated with the propagation of the shock waves is very short compared with the timescale associated with physical movement and separation of skin and structure fractured or damaged by the shock. Therefore, for the purpose of assessing the shock propagation through the cavities, the explosive damage to the hull can be ignored and the structure regarded as being intact. A further simplification can usefully be made by considering the structure to be rigid. This assumption would, if the analysis were quantitative, result in over-estimations of the shock strengths. However, for the purposes of a purely qualitative assessment, the assumption should be valid, in that the general trends of behaviour should not be materially altered.
It has already been argued that the shock wave emerging from the container was, in part, reflected back off the inner surface of the fuselage skin, forming a Mach stem shock wave which would then have tended to travel into the semi-circular lower lobe cavity. The Mach stem waves would have propagated away through this cavity in two directions:
|(i)||under the belly, between the frames [Appendix B, Figure B-3, detail A], and|
|(ii)||up the left side, expanding into the cavity formed by the longitudinal manifold chamber where it joins the lower lobe cavity.|
As part of a research program carried out into the design of ventilation systems for blast hardened installations intended to survive the long duration blast waves following the detonation of nuclear weapons, the propagation of blast waves along the primary passages and into the side branches of ventilation ducts was studied. The research showed that 90° bends in the ducts produced very little attenuation of shock wave pressure; a series of six right angle bends produced only a 30% pressure attenuation, together with an extension of the shock duration. It is therefore evident that the attenuation of shock waves propagating through the fuselage cavities, all of which were short with hardly any right angle turns, would have been minimal.
It was also demonstrated that secondary shock waves develop within the entrance to any side branch from the main duct, produced by the interaction of the primary shock wave with the geometric changes in the duct walls at the side-branch location. These secondary shock waves interact as they propagate into the side branch, combining together within a relatively short distance (typically 7 diameters) to produce a single, plane shock wave travelling along the duct axis. In a rigid, smooth walled structure, this mechanism produces secondary shock overpressures in the side branch of between 30% and 50% of the value of the primary shock, together with a corresponding attenuation of the primary shock wave pressure by approximately 20% to 25%.
This potential for the splitting up and re-transmission of shock wave energy within the lower hull cavities is of extreme importance in the context of this accident. Though the precise form of the interactions is too complex to predict quantitatively, it is evident that the lower hull cavities will serve to convey the overpressure efficiently to other parts of the aircraft. Furthermore, the cavities are not of serial form, i.e. they do not simply branch (and branch again) in a divergent manner, but instead form a parallel network of short cavities which reconnect with each other at many different points, principally along the crease beams. Thus, considerable scope exists for: the additive recombination of blast waves at cavity junctions; for the sustaining of the shock overpressure over a greater time period; and, for the generation of multiple shocks produced by the delay in shock propagation inherent in the different shock path (i.e. cavity) lengths.
Whilst it has not been possible to find a specific mechanism to explain the regions of localised skin separation and peel-back (i.e. the 'pressure blow' regions referred to in para 2.12.2), they were almost certainly the result of high intensity shock overpressures produced locally in those regions as a result of the additive recombination of shock waves transmitted through the lower hull cavities. It is considered that the relatively close proximity of the left side region of damage just below floor level at station 500, [Appendix B, Figure B-19, region D] to the forward end of the cargo hold may be significant insofar as the reflections back from the forward end of the hold would have produced a local enhancement of the shock overpressure. Similarly, 'end blockage effects' produced by the cargo door frame might have been responsible for local enhancements in the area of the belly skin separation and curl-back at station 560 [Appendix B, Figure B-19 and B-20, region E].
The separation of the large section of upper fuselage
skin [Appendix B, Figure B-19 and B-20, detail B] was almost certainly
associated with a local overpressure in the side cavities between the main
deck window line and the upper deck floor, where the cavity is effectively
closed off. It is considered that the most probable mechanism producing
this region of impulse overpressure was a reflection from the closed end
of the cavity, possibly combined with further secondary reflections from
the window assembly, the whole being driven by reflective overpressures
at the forward end of the longitudinal manifold cavity caused by the forward
end of the cargo hold. The local overpressure inside the sidewall cavity
would have been backed up by a general cabin overpressure resulting from
the floor breakthrough, giving rise to an increased pressure acting on
the inner face of the cabin side liner panels. This would have provided
pseudo mass to the panels, effectively preventing them from moving inwards
and allowing them to react the impulse pressure within the cavity, producing
the region of local high pressure evidenced by the region of quilting on
the skin panels [Appendix B, Figure B-19, region C].
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220.127.116.11 Propagation of shock waves into the cabin
The design of the air-conditioning/depressurisation-venting systems on the Boeing 747 (and on most other commercial aircraft) is seen as a significant factor in the transmission of explosive energy, as it provides a direct connection between the main passenger cabin and the lower hull at the confluence of the lower hull cavities below the crease beam. The floor level air conditioning vents along the length of the cabin provided a series of apertures through which explosive shock waves, propagating through the sub floor cavities, would have radiated into the main cabin.
Once the shock waves entered the cabin space, the form of propagation would have been significantly different from that which occurred in the cavities in the lower hull. Again, the precise form of such radiation cannot be predicted, but it is clear that the energy would potentially have been high and there would also (potentially) have been a large number of shock waves radiating into the cabin, both from individual vents and in total, with further potential to recombine additively or to 'follow one another up' producing, in effect, sustained shock overpressures.
Within the cabin, the presence of hard, reflective, surfaces are likely to have been significant. Again, the precise way in which the shock waves interacted is vastly beyond the scope of current analytical methods and computing power, but there clearly was considerable potential for additive recombination of the many different shock waves entering at different points along the cabin and the reflected shock waves off hard surfaces in the cabin space, such as the toilet and galley compartments and overhead lockers. These recombination effects, though not understood, are known phenomena. Appendix B, Figure B-26 shows how shock waves radiating from floor level might have been reflected in such a way as produce shock loading on a localised area of the pressure hull.
18.104.22.168 Supersonic gas flows
The gas produced by the explosive would have resulted in a supersonic flow of very high pressure gas through the structural cavities, which would have followed up closely behind the shock waves. Whilst the physical mechanisms of propagation would have been different from those of the shock wave, the end result would have been similar, i.e. there would have been propagation via multiple, linked paths, with potential for additive recombination and successive pressure pulses resulting from differing path lengths. Essentially, the shock waves are likely to have delivered initial 'pressure blows' which would then have been followed up immediately by more sustained pressures resulting from the high pressure supersonic gas flows.
2.13 Potential limitation of explosive damage
Quite clearly the detonation of high explosive material anywhere on board an aircraft is potentially catastrophic and the most effective means of protecting lives is to stop such material entering the aircraft in the first place. However, it is recognised that such risks cannot be eliminated entirely and it is therefore essential that means are sought to reduce the vulnerability of commercial aircraft structures to explosive damage.
The processes which take place when an explosive detonates inside an aircraft fuselage are complex and, to a large extent, fickle in terms of the precise manner in which the processes occur. Furthermore, the potential variation in charge size, position within the hull, and the nature of the materials in the immediate vicinity of the charge (baggage etc) are such that it would be unrealistic to expect to neutralise successfully the effect of every potential explosive device likely to be placed on board an aircraft. However, whilst the problem is intractable so far as a total solution is concerned, it should be possible to limit the damage caused by an explosive device inside a baggage container on a Boeing 747 or similar aircraft to a degree which would allow the aircraft to land successfully, albeit with severe local damage and perhaps resulting in some loss of life or injuries.
In Appendix E the problem of reducing the vulnerability
of commercial aircraft to explosive damage is discussed, both in general
terms and in the context of aircraft of similar size and form to the Boeing
747. In that discussion, those damage mechanisms which appear to have contributed
to the catastrophic structural failure of Flight PA103 are identified and
possible ways of reducing their damaging effects are suggested. These suggestions
are intended to stimulate thought and discussion by manufacturers, airworthiness
authorities, and others having an interest in finding solutions to the
problem; they are intended to serve as a catalyst rather than to lay claim
to a definitive solution.
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It was established that the detonation of an IED, loaded in a luggage container positioned on the left side of the forward cargo hold, directly caused the loss of the aircraft. The direct explosive forces produced a large hole in the fuselage structure and disrupted the main cabin floor. Major cracks continued to propagate from the large hole under the influence of the service pressure differential. The indirect explosive effects produced significant structural damage in areas remote from the site of the explosion. The combined effect of the direct and indirect explosive forces was to destroy the structural integrity of the forward fuselage, allow the nose and flight deck area to detach within a period of 2 to 3 seconds, and subsequently allow most of the remaining aircraft to disintegrate while it was descending nearly vertically from 19,000 to 9,000 feet.
The investigation has enabled a better understanding
to be gained of the explosive processes involved in such an event and to
suggest ways in which the effects of such an explosion might be mitigated,
both by changes to future design and also by retrospective modification
of aircraft. It is therefore recommended that Regulatory Authorities and
aircraft manufacturers undertake a systematic study with a view to identifying
measures that might mitigate the effects of explosive devices and improve
the tolerance of the aircraft structure and systems to explosive damage.
|(i)||The crew were properly licenced and medically fit to conduct the flight.|
|(ii)||The aircraft had a valid Certificate of Airworthiness and had been maintained in compliance with the regulations.|
|(iii)||There was no evidence of any defect or malfunction in the aircraft that could have caused or contributed to the accident.|
|(iv)||The structure was in good condition and the minimal areas of corrosion did not contribute to the in-flight disintegration.|
|(v)||One minor fatigue crack approximately 3 inches long was found in the fuselage skin but this had not been exploited during the disintegration.|
|(vi)||An improvised explosive device detonated in luggage container serial number AVE 4041 PA which had been loaded at position 14L in the forward hold. This placed the device approximately 25 inches inboard from the skin on the lower left side of the fuselage at station 700.|
|(vii)||The analysis of the flight recorders, using currently accepted techniques, did not reveal positive evidence of an explosive event.|
|(viii)||The direct explosive forces produced a large hole in the fuselage structure and disrupted the main cabin floor. Major cracks continued to propagate from the large hole under the influence of the service pressure differential.|
|(ix)||The indirect explosive effects produced significant structural damage in areas remote from the site of the explosion.|
|(x)||The combined effect of the direct and indirect explosive forces was to destroy the structural integrity of the forward fuselage.|
|(xi)||Containers and items of cargo ejected from the fuselage aperture in the forward hold, together with pieces of detached structure, collided with the empennage severing most of the left tailplane, disrupting the outer half of the right tailplane, and damaging the fin leading edge structure.|
|(xii)||The forward fuselage and flight deck area separated from the remaining structure within a period of 2 to 3 seconds.|
|(xiii)||The No 3 engine detached when it was hit by the separating forward fuselage.|
|(xiv)||Most of the remaining aircraft disintegrated while it was descending nearly vertically from 19,000 to 9,000 feet.|
|(xv)||The wing impacted in the town of Lockerbie producing a large crater and creating a fireball.|
The in-flight disintegration of the aircraft was
caused by the detonation of an improvised explosive device located in a
baggage container positioned on the left side of the forward cargo hold
at aircraft station 700.
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4. SAFETY RECOMMENDATIONS
The following Safety Recommendations were made during the course of the investigation :
|4.1||That manufacturers of existing recorders which use buffering techniques give consideration to making the buffers non-volatile, and the data recoverable after power loss.|
|4.2||That Airworthiness Authorities re-consider the concept of allowing buffered data to be stored in a volatile memory.|
|4.3||That Airworthiness Authorities consider requiring the CVR system to contain a short duration, i.e. no greater than 1 minute, back-up power supply to enable the CVR to respond to events that result in the almost immediate loss of the aircraft's electrical power supply.|
|4.4||That the Department of Transport fund a study to devise methods of recording violent positive and negative pressure pulses, preferably utilising the aircraft's flight recorder systems.|
|4.5||That Airworthiness Authorities and aircraft manufacturers undertake a systematic study with a view to identifying measures that might mitigate the effects of explosive devices and improve the tolerance of aircraft structure and systems to explosive damage.|
M M Charles
Inspector of Accidents
Department of Transport