Investigation Summary
The investigation focused on the failure of the number 9 combustor can, which had been previously repaired. The repair involved welding cracks, but the thermal stresses of operation caused the can to fracture again, leading to the uncontained ejection of a large section. This fragment struck the wing at a critical point, puncturing a fuel tank access panel. The resulting fuel leak was estimated at 450 to 680 liters per minute. The disaster's high death toll was attributed to the crew's decision to turn off the runway, which positioned the aircraft so that the wind pushed the fire against the fuselage. The fire breached the aluminum skin between 5 seconds before and 13 seconds after the aircraft stopped, far faster than industry safety standards of the time predicted. The cabin interior materials also produced highly lethal concentrations of carbon monoxide and hydrogen cyanide.
Final Conclusions
The AAIB concluded that the primary cause was the uncontained failure of the left engine, but the fatalities were caused by the rapid influx of fire and toxic smoke into the cabin. Contributing factors included the vulnerability of the wing tank access panels, the lack of effective fire suppression inside the cabin, and the highly toxic nature of the burning interior materials. The accident led to a complete overhaul of aviation safety standards regarding cabin interiors, including the introduction of fire-resistant seat covers, floor-level emergency lighting, and wider access to overwing exits.
Photographic Evidence (1)
Video Analysis
British Airtours Flight 28M: The Manchester Airport Disaster — Analysis of the 1985 engine failure and subsequent fire that led to 55 fatalities. The video examines the uncontained combustor failure and the resulting changes to aircraft evacuation and fire safety standards.
If playback is blocked, the owner has disabled embedding — use the link above.
Airframe & Maintenance
Crew Experience
Captain
First Officer
Systems & Failure Modes
Pratt & Whitney JT8D-15A
The engine that suffered an uncontained failure of the combustion chamber outer case.
Combustor Can
Component #9 fractured due to thermal fatigue, leading to the catastrophic engine failure.
Wing Tank Access Panel
The impact point of the ejected engine fragment, which caused the massive fuel leak.
Interesting Facts
- 0148 of the 55 fatalities were caused by toxic gas and smoke inhalation rather than direct burns.
- 02The fire penetrated the fuselage skin within 5 to 13 seconds of the aircraft stopping.
- 03The fuel leak rate was between 118 and 179 US gallons per minute.
- 04The number 9 combustor can had been repaired multiple times prior to the failure.
- 05The turn off the runway placed the aircraft in a position where a 6-7 knot wind blew the fire into the fuselage.
Safety Actions & Advisories
Cabin Interior Standards
Mandated the use of fire-blocking seat covers and more fire-resistant wall and ceiling panels.
Evacuation Path Improvements
Introduced floor-level emergency lighting and increased the minimum width of the path to overwing exits.
Engine Maintenance Procedures
Revised inspection and repair criteria for combustor cans to prevent thermal fatigue failures.
Known Controversies & Unanswered Questions
Smoke Hood Implementation
Reference ↗Following the disaster, there was a significant public and parliamentary debate regarding the mandatory provision of smoke hoods for passengers, which the CAA ultimately decided against due to concerns over evacuation delays.