Official AARs for TWA Flight 800, UAL Flight 811, Pan Am Flight 103, Air India Flight

1490 Pages·2010·22.09 MB·English

by  John Smith

Smith AAR PA 103
John Barry Smith
www.corazon.com
[email protected]
Copyright May 2002
All Rights Reserved
AIRCRAFT
ACCIDENT
REPORT
Pan Am Flight 103
Part I
Consideration of Reasonable Probable Causes
Report on the accident to
Boeing 747-121, N739PA
at Lockerbie, Dumfriesshire, Scotland
on 21 December 1988
by John Barry Smith,
Independent Aircraft Accident Investigator
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Smith AAR PA 103
Part I: Consideration of Reasonable Probable Causes
Abstract and excerpts from AAIB 2/90: 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.
The AAIB 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.
This Smith Pan Am Flight 103 AAR concludes that there are four reasonable alternatives to the
bomb explanation based on the subsequent similar accidents of United Airlines Flight 811 and
Trans World Airlines Flight 800. Of the four reasonable alternatives, two can be ruled out with
confidence: Missile strike and center fuel tank explosion; and two ruled in: Firing of a rather large
shotgun and the shorted wiring/forward cargo door rupture/explosive decompression/inflight
breakup explanation which closely matches the probable cause of the United Airlines Flight 811
accident. Since the discovered hazards of faulty wiring or switch and nonplug cargo doors
currently exist in the five hundred early model Boeing 747s in service, further official investigation
is warranted and urgently needed.
Table of Contents
Part I: Consideration of Reasonable Probable Causes
1. Factual Information
1.1 History of the Flight
2. Premise Explanations for Pan Am Flight 103
2.1 Explosion in flight in the forward cargo compartment leading to inflight breakup.
2.1.2 Discussion
2.1.3 Conclusion:
2.2.1 Premise: Surface to air or air to air missile strike inflight:
2.2.2. Discussion:
2.2.3 Conclusion:
2.3.1 Premise: Center Fuel Tank explosion with undetermined ignition source:
2.3.2 Discussion:
2.3.3 Conclusion:
2.4.1 Premise: Explosion in the forward cargo compartment on the starboard side caused by
explosive decompression caused by structural failure of a ruptured open forward cargo door at one
or both of the midspan latches caused by faulty electrical wiring or switch shorting on the door
unlatch motor.
2.4.2. Discussion:
2.4.3 Conclusion:
2.5.1. Premise: Explosion of a improvised explosive device (bomb) in the forward cargo
compartment on the left side.
2.5.2 Discussion:
2.5.3 Conclusion:
2.6.1 Premise: Firing of a rather large shotgun in a baggage container.
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2.6.2. Discussion:
2.6.3 Conclusion:
2.7. Summary:
3. Sequence of disintegration.
4. Hindsight Pattern.
5. Specific Conclusions for Pan Am Flight 103:
6. Concluding Comment:
Part II: Comparison to Similar Accidents
1. Introduction:
2. Purpose of Part II:
3. Premise Explanation: Explosion in the forward cargo compartment of explosive
decompression caused by structural failure of ruptured open forward cargo door at one or both of
the midspan latches caused by faulty electrical wiring:
4. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had probable causes which were initially thought to be bomb explosions:
5. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had the original cause of bomb explosion modified.
6. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had breakups in their airframes in a similar amidships location.
7. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had at least nine never recovered bodies.
8. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had passengers that showed explosive decompression type injuries and no
evidence of bomb explosion injuries.
9. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had experienced a sudden, loud, audible sound on the cockpit voice recorder at
event start time:
10. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had the source of the sudden, loud, audible sound as a bomb explosion
disputed and the source of the sudden, loud, audible sound as an explosive decompression
supported.
11. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had an abrupt power cut to the data recorders immediately after a sudden, loud,
audible sound at event start time.
12. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had an explosion in or adjacent to the forward cargo compartment.
13. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had similar shattered fuselage skin in and around the forward cargo door.
14. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had relatively mild damage on the port side of the nose forward of the wing
directly opposite the shattered zone around the forward cargo door at the same initial event time.
15. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had similar damage to their airframe structures from inflight ejected debris.
16. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had foreign object damage to engine number three.
17. Air India Flight 182, Pan Am Flight 103, United Airlines Flight 811, and Trans World
Airlines Flight 800 had incomplete reports of the status of the forward cargo door.
18. Air India Flight 182, Pan Am Flight 103, and Trans World Airlines Flight 800, and United
Airlines Flight 811 to a much lesser extent, had similar debris patterns on the surface of the ground
or sea bottom.
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19. Summary of matching evidence for all aircraft:
20. Summary of matching evidence between Pan Am Flight 103 and United Airlines Flight 811
specifically:
21. Cargo Door Operation for Boeing 747:
22. Inadvertent Cargo Door Opening Causes:
23. Wiring:
24. Comment:
25. General Conclusions for Air India Flight 182, Pan Am Flight 103, United Airlines Flight
811, and Trans World Airlines Flight 800:
26. Specific Conclusions for Pan Am Flight 103:
27. Contributing causes:
28. Recommendations:
Part III: Door Story
Forward Cargo Door Areas Compared for United Airlines Flight 811, Pan Am Flight 103, Air
India Flight 182, and Trans World Airlines Flight 800.
1. Introduction.
2. Normal Operation.
3. United Airlines Flight 811.
4. Air India Flight 182.
5. Pan Am Flight 103.
6. Trans World Airlines Flight 800
7. Conclusions.
Part IV: Comparison between AAIB 2/90 and Smith AAR for PA 103
1. Observations:
Engine number three was the only engine to fall apart from the others; it was the only one to catch
fire; and it contained ingested debris from within the aircraft.
2. Observation:
Forward fuselage section was bent to starboard and then entirely detached.
3. Observations:
There are only two small fragments of plastic which are the only ‘hard’ evidence of a bomb (there
is much evidence of an explosive decompression).
4. Observation:
The overall evidence of damage from an explosion of a powerful plastic bomb in the port side of
the forward cargo hold is very limited.
5. Observation:
The sudden loud sound on the cockpit voice recorder can be linked to the explosive decompression
sound of a cargo door opening in flight on an airliner.
6. Observation:
Inflight damage to the airframe of Pan Am Flight 103 does not match airframe damage from a
staged bomb explosion event in a Boeing 747 at Bruntingthorpe.
7. Observations:
In the AAIB report there is a grammatical error in verb tense and irrelevant inclusions of phrases
and conclusions for bomb explosion which are unsupported by evidence.
8. Observations:
There are two photographs in the AAIB report of the port ‘bomb’ side hole
9. Observation:
The latch status of the forward cargo door is omitted whilst the latch status of the identical aft cargo
door (frames 1800-1920) and the CRAF door is given and stated as ‘latched.’
10. Observation:
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There is much more airframe damage on the starboard side of the airframe away from the ‘bomb’
explosion in areas such as the leading edge of the right wing and the right horizontal stabilizer.
11. Observation:
There was a single primary return received by both Great Dun Fell and Claxby radars
approximately 16 seconds before SSR returns were lost.
12. Observation:
The aircraft, Flight PA103 from London Heathrow to New York, had been in level cruising flight
at flight level 310 (31,000 feet)
13.Observation:
Pan Am Flight 103 was proceeding normally until a sudden, loud, audible sound was immediately
followed by an abrupt power cut to the data recorders.
14. Observation:
The evidence of Pan Am Flight 103 was matched to Air India Flight 182 in AAIB 2/90 but not to
United Airlines Flight 811.
15. Conclusions.
Glossary
Acronyms
References and Source Materials
Definitions
Appendices:
Appendix A: Boeing 747 Accidents
Appendix B: Avianca Accident
Appendix C: Comet Accidents
Appendix D: DC-10 Accidents
Appendix E: Boeing History
Appendix F: Cargo Door Incidents
Appendix G: Wiring
Appendix H: Miscellaneous Accidents
Appendix I: Questions
Appendix J; Bruntingthorpe
Appendix K: Weapon Firings
Appendix L: AAIB 2/90
Appendix M: NTSB 92/02
Appendix N: Pressure Relief Doors
Glossary:
Acronyms and Abbreviations:
CASB, Canadian Aviation Safety Board, now TSB, Transportation Safety Board, of Canada
UK AAIB, United Kingdom Air Accidents Investigation Branch, Farnborough, U.K
NTSB USA, National Transportation Safety Board, United States of America
CVR, cockpit voice recorder
DFDR, digital flight data recorder
ATC, air traffic control
AAR, aircraft accident report
MEC, main equipment compartment
PSI, pounds per square inch
FOD, foreign object damage
IED, improvised explosive device
KTS, knots
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TAS, true air speed
IAS, indicated air speed
AI, Air India
PA, Pan Am World Airways
UAL, United Airlines,
TWA, Trans World Airlines
JAL, Japan Air Lines
NAVAVNSAFECEN, Naval Aviation Safety Center
a.c. alternating current
AC advisory circular
AD airworthiness directive
ALPA Air Line Pilots Association
amp ampere
AOA angle-of-attack
APU auxiliary power unit
ARTCC air route traffic control center
ASR airport surveillance radar
ATC air traffic control
ATP airline transport pilot
CAM cockpit area microphone
CFR Code of Federal Regulations
c.g. center of gravity
CVR cockpit voice recorder
CWT center wing fuel tank
d.c. direct current
DNA deoxyribonucleic acid
E/E electrical/electronics
EME electromagnetic environment
EMI electromagnetic interference
EPR engine pressure ratio
F Fahrenheit
FAA Federal Aviation Administration
FARs Federal Aviation Regulations
FBI Federal Bureau of Investigation
FDR flight data recorder
FQIS fuel quantity indication system
GPS global positioning system
HF high frequency
Hg mercury
HIRF high-intensity radiated fields
Hz hertz (cycles per second)
JFK John F. Kennedy International Airport (New York, New York)
MHz megahertz
msl mean sea level
NASA National Aeronautics and Space Administration
NOAA National Oceanic and Atmospheric Administration
NPRM notice of proposed rulemaking
PETN pentaerythritol tetranitrate
P/N part number
psi (pressure expressed in) pounds per square inch
P&W Pratt & Whitney
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RDX cyclotrimethylenetrinitramine
SB service bulletin
SDR service difficulty report
SL service letter
S/N serial number
STA body station
STC supplemental type certificate
TWA Trans World Airlines, Inc.
USAF U.S. Air Force
USCG U.S. Coast Guard
References and Source Materials:
AAIB Aircraft Accident Report No 2/90, Pan Am 103, 22 December 1988, Boeing 747
Blacks Law Dictionary, Sixth Edition 1990
Canadian Aviation Bureau Aviation Occurrence, Air India Boeing, 747-237B VT-EFO Report
Indian Kirpal Report, Report Of The Court Investigating Accident To Air India Boeing 747
Aircraft VT-ETO, "Kanishka" On 23rd June 1985
NAVAVNSAFECEN Investigation 69-67, RA-5C, 14 June, 1967
Netherlands Aviation Safety Board AAR 92-11, El Al Flight 1862, Boeing 747
NTSB AAR 90/01 UAL Flight 811, 23 February 1989, Boeing 747
NTSB AAR 92/02 UAL Flight 811, 23 February 1989, Boeing 747
NTSB AAR 00/03 TWA Flight 800, 17 July 1996, Boeing 747
NTSB AAR 93/06, JAL Flight 46E, 31 March, 1993, Boeing 747
Definitions: Definitions as used in this report:
Bomb: 'Bomb' may mean an explosive device designed to release destructive material at high
velocity upon detonation; an explosive device placed in an aircraft with an intent to detonate.
Cargo Door: In the Boeing 747 both the forward and aft lower cargo doors are similar in
appearance and operation. They are located on the lower starboard side of the fuselage and are
outward opening and nonplug. The door opening is approximately 110 inches wide by 99 inches
high, as measured along the fuselage.
Cargo Compartments: The forward and aft freight holds are used for the storage of cargo and
baggage in standard air-transportable containers. The forward freight compartment has a length of
approximately 40 feet and a depth of approximately 6 feet. The containers are loaded into the
forward hold through a large cargo door on the starboard side of the aircraft.
Conclusion of fact: An inference drawn from the subordinate or evidentiary facts.
Conclusive evidence: That which is incontrovertible, either because the law does not permit it to be
contradicted, or because it is so strong and convincing as to overbear all proof to the contrary and
establish the proposition in question beyond reasonable doubt.
Ear Barotrauma: Injury to the tympanic membrane (eardrum) when a sudden pressure differential
exists between the middle ear cavity and the external ear.
Evidence: A species of proof, or probative matter, legally presented at the trial of an issue, by the
act of the parties and through the medium of witnesses, records, documents, exhibits, concrete
objects, etc., for the purpose of inducing belief in the minds of the court or jury as to their
contention.
Circumstantial Evidence: The proof of various facts or circumstances which usually attend the main
fact in dispute, and therefore tend to prove its existence, or to sustain, by their consistency, the
hypothesis claimed. Testimony not based on actual personal knowledge or observation of the facts
in controversy, but of other facts from which deductions are drawn, showing indirectly the facts
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sought to be proved. Evidence of facts or circumstances from which the existence or nonexistence
of fact in issue may be inferred. Inferences drawn from facts proved.
Direct Evidence: Evidence in the form of testimony from a witness who actually saw, heard, or
touched the subject of questioning.
Tangible Evidence: Evidence which consists of something that can be seen or touched. In contrast
to testimonial evidence, tangible evidence is real evidence.
Expert: One who is knowledgeable in a specialized field, that knowledge being obtained from
either education or personal experience. One who by reason of education or special experience has
knowledge respecting a subject matter about which persons having no particular training are
incapable of forming an accurate opinion or making a correct deduction.
Expert Testimony: Opinion evidence of some person who possesses special skill or knowledge in
some science, profession, or business which is not common to the average man and which is
possessed by the expert by reason of his special study or experience.
Expert Witness: One who by reason of education or specialized experience possesses superior
knowledge respecting a subject about which persons have no particular training are incapable of
forming an accurate opinion, or deducing correct conclusions. One possessing, with reference to
particular subject, knowledge not acquired by ordinary persons.
Explosion: To burst or cause to burst violently and noisily. The sudden and rapid escape of gases
from a confined space, accompanied by high temperatures, violent shock, and loud
noise.
Explosive Decompression: Explosive decompression is an aviation term used to mean a sudden
and rapid loss of cabin pressurization of higher internal air pressure venting outside to the lower
pressure air.
Finding: The result of the deliberations of a jury or a court. A decision upon a question of fact
reached as the result of a judicial examination or investigation by a court, jury, referee, coroner,
etc. A recital of the facts found.
Outward Opening Nonplug: A type of cargo door which undergoes stress to open in flight under a
high pressure differential because it opens outward and the door does not 'plug up' or 'block' the
opening.
Premise: A statement of fact or a supposition made or implied as a basis of argument.
Reasonable doubt: The standard used to determine the guilt of innocence of a person criminally
charged. Reasonable doubt which will justify acquittal is doubt based on reason and arising from
evidence or lack of evidence, and it is doubt which a reasonable man or woman might entertain,
and it is not fanciful doubt, is not imagined doubt, and is not doubt that juror might conjure up to
avoid performing an unpleasant task or duty. Reasonable doubt is such a doubt as would cause
prudent men to hesitate before acting in matters of importance to themselves. Doubt based on
reasons which arise from evidence or lack of evidence.
Starboard Side: The right side of the fuselage looking from aft to forward. The port side is the left
side looking aft to forward. The starboard side of the aircraft faces the viewer when the nose is to
the right. Both cargo doors are on the starboard side of the Boeing 747.
Shorted wiring/forward cargo door rupture/explosive decompression/inflight breakup explanation:
Mechanical explanation for the inflight breakup of Air India Flight 182, Pan Am Flight 103, United
Airlines Flight 811, and Trans World Airlines Flight 800 as caused by an explosion in the forward
cargo compartment of explosive decompression when the forward cargo door ruptures open in
flight, probably at one or both of the midspan latches and probably caused by faulty wiring
inadvertently turning on the door unlatch motor.
Introduction:
This AAR has been created by an independent aircraft accident investigator who has no affiliation
with the manufacturer, law enforcement agencies, attorney, airlines, or victim's families. Much of
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the text is quoted verbatim from official government documents. The primary document is Aircraft
Accident Report No 2/90 (EW/C1094) produced by the Air Accidents Investigation Branch of the
United Kingdom.
Any reference to an 'explosion' does not imply a bomb explosion. An ‘explosion’ can be caused
by a fuel tank explosion or an explosive decompression explosion. A reference to an 'improvised
explosive device' does not imply a bomb as there are devices which can be improvised,
intentionally or unintentionally, to cause an explosion such as blasting caps, firecrackers,
fireworks, starting pistols, and gas tanks. Evidence of explosive residue does not imply the
explosion of a bomb as the residue could have been put there intentionally as part of a dog sniffing
drill or the residue could have come from troop's clothing rubbing on the seats and thus have a
benign explanation. Whenever there is evidence of an explosion in an aircraft, and there certainly
was an explosion in Pan Am Flight 103, corroborating evidence is required to rule in or rule out
the possibilities of a bomb explosion, a missile hit, a fuel tank explosion, or an explosive
decompression explosion from metal fatigue or inadvertent fuselage rupture such as caused by a
suddenly ruptured open cargo door. Each premise shall be examined and supported by evidence.
This Smith AAR has the benefit of hindsight with the ability to review and analyze dozens of
subsequent Boeing 747 accidents as well as evaluating previous accidents of other types. There
exists an early model Boeing 747 at Bruntingthorpe that suffered a staged bomb explosion in a
cargo compartment which left much actual evidence. There also exists an early model Boeing 747,
United Airlines Flight 811, that suffered an explosion of explosive decompression in a cargo
compartment which left much evidence. Pan Am Flight 103 was an early model Boeing 747 that
suffered an explosion in a cargo compartment which left much evidence which can be compared
with other similar events. This AAR shall compare the evidence of Pan Am Flight 103 to that of the
other other three explosive events to identify which of the three is most closely matched, the bomb
explosion, the center fuel tank explosion, or the ruptured open cargo door explosive
decompression explosion.
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 taxi 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
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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.
The AAIB report concludes that the detonation of an improvised explosive device led directly to the
destruction of the aircraft.
2. Premise Explanations for Pan Am Flight 103
The AAIB report conclusion is interpreted by most to mean a bomb blew Pan Am Flight 103 out of
the sky. That interpretation may not be correct as there are alternatives based on subsequent similar
accidents such as United Airlines Flight 811 and Trans World Airlines Flight 800. An alternative
probable cause to Pan Am Flight 103 must be considered if the alternative were:
1. Plausible.
2. Reasonable.
3. Well documented by official investigative reports.
4. Has close precedent.
5. Reveals current hazard.
There is one solid conclusion and five reasonable explanations for probable cause based upon
subsequent similar fatal inflight accidents to early model Boeing 747s:

2.1. Explosion in flight in the forward cargo compartment leading to inflight breakup as an
initial event and is a solid conclusion.
2.2. Missile strike. (Brought up by Trans World Airlines Flight 800.)
2.3. Center fuel tank explosion with undetermined ignition source. (Brought up by Trans World
Airlines Flight 800.)
2.4. Shorted wiring/forward cargo door rupture/explosive decompression/inflight breakup.
(Brought up by United Airlines Flight 811.)
2.5. Explosion in flight from a bomb in the forward cargo compartment. (Brought up by Air
India Flight 182, Pan Am Flight 103, Trans World Airlines Flight 800, and United Airlines Flight
811.)
2.6 Firing of a rather large shotgun in forward cargo compartment. (Brought up by Pan Am
Flight 103.)
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