ZS-SAS, the aircraft involved in the accident
|Date||28 November 1987|
|Summary||In-flight fire in cargo hold leading to loss of control and in-flight breakup|
|Site||Indian Ocean, 134 nautical miles (248 km) northeast of Mauritius |
|Aircraft type||Boeing 747-244BM Combi|
|Operator||South African Airways|
|Flight origin||Chiang Kai-shek International Airport,|
Plaine Magnien, Mauritius
|Destination||Jan Smuts International Airport, Johannesburg,|
South African Airways Flight 295 was a commercial flight from Chiang Kai-shek International Airport, Taipei, Taiwan to Jan Smuts International Airport, Johannesburg, South Africa, with a stopover in Plaisance Airport, Plaine Magnien, Mauritius. On 28 November 1987, the aircraft serving the flight, a Boeing 747 Combi named Helderberg, experienced a catastrophic in-flight fire in the cargo area, broke-up in mid-air, and crashed into the Indian Ocean east of Mauritius, killing all 159 people on board. An extensive salvage operation was mounted to try to recover the black box recorders, one of which was recovered from a depth of 4,900 metres (16,100 ft).
The official inquiry, headed by Judge Cecil Margo, was unable to determine the cause of the fire. This lack of a conclusion led to conspiracy theories being advanced and a subsequent post-apartheid investigation, in the years following the accident.
The Boeing 747-200B Combi model permits the mixing of passengers and cargo on the main deck according to load factors on any given route and Class B cargo compartment regulations. Flight 295 had 140 passengers and six pallets of cargo on the main deck. The master waybills stated that 47,000 kilograms (104,000 lb) of baggage and cargo were loaded on the aircraft. A Taiwanese customs official performed a surprise inspection of some of the cargo; he did not find any cargo that could be characterised as suspicious.
The flight crew consisted of 49-year-old captain Dawie Uys, with 13,843 hours' experience; 36-year-old first officer David Attwell and 37-year-old relief first officer Geoffrey Birchall, with 7,362 and 8,749 hours' experience respectively; and 45-year-old flight engineer, Giuseppe "Joe" Bellagarda and 34-year-old relief flight engineer, Alan Daniel, with 7,804 hours and 1,595 hours of experience respectively.
Thirty-four minutes after departure, the crew contacted Hong Kong air traffic control to obtain clearance from waypoint ELATO ( ) to ISBAN. A position report was made over ELATO at 15:03:25, followed by waypoints SUNEK at 15:53:52, ADMARK at 16:09:54 and SUKAR ( ) at 16:34:47. The aircraft made a routine report to the South African Airways base at Johannesburg at 15:55:18.
At some point during the flight, believed to be during the beginning of its landing approach, a fire developed in the cargo section on the main deck which was probably not extinguished before impact. The 'smoke evacuation' checklist calls for the aircraft to be depressurised, and for two of the cabin doors to be opened. No evidence exists that the checklist was followed, or that the doors were opened. A crew member might have gone into the cargo hold to try to fight the fire. A charred fire extinguisher was later recovered from the wreckage on which investigators found molten metal.
|Transcript of communication with Mauritius air traffic control|
|Time||Speaker||Dialog||Comment from official enquiry|
|23:48:51||295||Eh, Mauritius, Mauritius, Springbok Two Niner Five.|
|23:49:00||ATC||Springbok Two Nine Five, eh, Mauritius, eh, good morning, eh, go ahead.|
|23:49:07||295||Eh, good morning, we have, eh, a smoke, eh, eh, problem and we're doing emergency descent to level one five, eh, one four zero.|
|23:49:18||ATC||Confirm you wish to descend to flight level one four zero.|
|23:49:20||295||Ja, we have already commenced, an, due to [a] smoke problem in the aeroplane.|
|23:49:25||ATC||Eh, roger, you are clear to descend immediately to flight level one four zero.|
|23:49:30||295||Roger, we will appreciate if you can alert the fire, ehp, ehp eh, eh|
|23:49:40||ATC||Do you wish to eh, do you request a full emergency?|
|23:49:48||295||Okay Joe, kan jy...vir ons||Okay Joe can you...for us|
|23:49:51||ATC||Springbok Two Nine Five, Plaisance.|
|23:49:54||295||Sorry, go ahead?|
|23:49:56||ATC||Do you, eh, request a full emergency please, a full emergency?|
|23:50:00||295||Affirmative, that's Charlie Charlie.|
|23:50:02||ATC||Roger, you declare a full emergency, roger.|
|23:50:40||ATC||Springbok Two Nine Five, Plaisance.|
|23:50:44||295||Eh, go ahead.|
|23:50:46||ATC||Request your actual position please and your DME distance?|
|23:50:51||295||Eh, we haven't got the DME yet.|
|23:50:55||ATC||Eh, roger and your actual position please.|
|23:51:00||295||Eh, say again.|
|23:51:02||ATC||Your actual position.|
|23:51:08||295||Now we've lost a lot of electrics, we haven't got anything on the, on the aircraft now.|
|23:51:12||ATC||Eh, roger, I declare a full emergency immediately.|
|23:52:19||ATC||Eh, Springbok Two Nine Five, do you have an Echo Tango Alfa Plaisance please?|
|23:52:30||ATC||Springbok Two Nine Five, Plaisance.|
|23:52:33||ATC||Do you have an Echo Tango Alfa Plaisance please?|
|23:52:36||295||Ja, eh, zero zero, eh eh eh three zero.|
|23:52:40||ATC||Roger, zero zero three zero, thank you.|
|23:52:50||295||Hey Joe, shut down the oxygen left.||Inadvertent transmission from the aircraft|
|23:52:52||ATC||Sorry, say again please?|
|00:01:34||295||Eh, Plaisance, Springbok 295, we've opened the door[s] to see if we (can?)...we should be OK|
|00:01:36||295||Look there (?)||Exclamation by someone else, and is said over the last part of the previous sentence|
|00:01:45||295||Donnerse deur t...||Close the bloody door (More directly translated: Damned door c...)|
|00:01:57||295||Joe, switch up quickly, then close the hole on your side.|
|00:02:10||295||Pressure(?) twelve thousand|
|00:02:14||295||...Genoeg is...Anders kan ons vlug verongeluk||...Is enough...otherwise our flight could come to grief (More directly translated: ...enough is... otherwise our flight might have an accident / end in calamity)|
|00:02:25||295||Carrier wave only|
|00:02:38||295||Eh Plaisance, Springbok Two Nine Five, do [did] you copy?|
|00:02:41||ATC||Eh negative, Two Nine Five, say again please, say again.|
|00:02:43||295||We're now sixty five miles.|
|00:02:45||ATC||Confirm sixty five miles.||Incorrectly understood by air traffic control to mean that the aircraft was 65 miles from the airport; in fact it was 65 miles from waypoint Xagal, and 145 miles from the airport.|
|00:02:47||295||Ja, affirmative Charlie Charlie.|
|00:02:50||ATC||Eh, Roger, Springbok eh Two Nine Five, eh re you're recleared flight level five zero. Recleared flight level five zero.|
|00:02:58||295||Roger, five zero.|
|00:03:00||ATC||And, Springbok Two Nine Five copy actual weather Plaisance Copy actual weather Plaisance. The wind one one zero degrees zero five knots. The visibility above one zero kilometres. And we have a precipitation in sight to the north. Clouds, five oktas one six zero zero, one okta five thousand feet. Temperature is twenty two, two two. And the QNH one zero one eight hectopascals, one zero one eight over.|
|00:03:28||295||Roger, one zero one eight.|
|00:03:31||ATC||Affirmative, eh and both runways available if you wish.|
|00:03:43||ATC||And two nine five, I request pilot's intention.|
|00:03:46||295||Eh, we'd like to track in eh, on eh one three.|
|00:03:51||ATC||Confirm runway one four.|
|00:03:56||ATC||Affirmative and you're cleared, eh direct to Foxtrot Foxtrot. You report approaching five zero||Clearance granted to the Flic-en-Flac non-directional navigation beacon.|
|00:04:02||295||Kay.||Last transmission from the aircraft|
|00:08:00||ATC||Two Nine Five, Plaisance.|
|00:08:11||ATC||Springbok Two Nine Five, Plaisance.|
|00:08:35||ATC||Springbok Two Nine Five Plaisance (No answer)|
The fire started to destroy the aircraft's important electrical systems, resulting in loss of communication and control of the aircraft. At exactly 00:07 UTC (4:07 local time), the aircraft broke apart in mid-air, the tail section breaking off first, due to the fire beginning to burn the structure of the aircraft, and crashed into the Indian Ocean, about 134 nautical miles (154 miles) from the Airport.
After communication with Flight 295 was lost for 36 minutes, at 00:44 (04:44 local time), Air Traffic Control at Mauritius formally declared an emergency.
When the Helderberg last informed Mauritian air traffic control of its position, its report was incorrectly understood to be relative to the airport rather than its next waypoint, which caused the subsequent search to be concentrated too close to Mauritius. The United States Navy sent aircraft from Diego Garcia, which were used to conduct immediate search and rescue operations in conjunction with the French Navy. By the time the first surface debris was located 12 hours after impact, it had drifted considerably from the impact location. Oil slicks and eight bodies showing signs of extreme trauma appeared in the water. All 140 passengers and 19 crew on the manifest were killed.
After recovery of the wreckage from 4,000 m (13,000 ft) below the surface of the ocean, the aircraft's fuselage and cabin interior were partly reassembled in one of SAA's hangars at Jan Smuts Airport where it was examined and finally opened for viewing to the airline's staff and selected members of the public.
Rennie Van Zyl, the head Southern African investigator, examined three wristwatches from the baggage recovered from the surface; two of the watches were still running according to Taiwan time. Van Zyl deduced the approximate time of impact from the stopped watch. The aircraft crashed at 00:07:00, around three minutes after the last communication with air traffic control. Immediately after the crash, the press and public opinion suspected that terrorism brought down the Helderberg. Experts searched for indicators of an explosion on the initial pieces of wreckage discovered, such as surface pitting, impact cavities and spatter cavities caused by white hot fragments from explosive devices that strike and melt metal alloys found in aircraft structures. Experts found none of this evidence. The investigators drew blood samples from two of the recovered bodies and found that the bodies had soot in their tracheae, indicating that they had died from smoke inhalation before the aircraft had crashed.
The South Africans mounted an underwater search, named Operation Resolve, to try to locate the wreckage. The underwater locator beacons (ULBs) attached to the flight recorders were not designed for deep ocean use; nevertheless, a two-month-long sonar search for them was carried out before the effort was abandoned on 8 January 1988 when the ULBs were known to have stopped transmitting (at the time a ULB had to generate sonic pulses for 30 days).Steadfast Oceaneering, a specialist deep ocean recovery company in the US, was contracted at great expense to find the site and recover the flight recorders. The search area is described as being comparable in size to that of the RMS Titanic, with the water at 5,000 metres (16,000 ft) being considerably deeper than any previously successful salvage operation. The wreckage was found within two days of Steadfast Oceaneering commencing its search.
Three debris fields were found:  On 6 January 1989, the cockpit voice recorder (CVR) was salvaged successfully from a record depth of 4,900 metres (16,100 ft) by the remotely operated vehicle (ROV) Gemini, but the flight data recorder was never found., and . These locations were spread 1.5 km (0.93 mi), 2.3 km (1.4 mi) and 2.5 km (1.6 mi) apart, indicating that the aircraft broke up in mid-air (it was suggested that the tail separated first).
Van Zyl took the voice recorder to the United States National Transportation Safety Board (NTSB) in Washington, DC, to show his goodwill and to ensure neutral observers. Van Zyl believes that if he kept the CVR in South Africa he could have been accused of covering up the truth. At the NTSB, Van Zyl felt frustration that the degraded (but still functional) CVR, which had been in the deep ocean for fourteen months, did not initially yield any useful information. Around 28 minutes into the recording the CVR indicated that the fire alarm sounded. Fourteen seconds after the fire alarm, the circuit breakers began to pop. Investigators believe that around 80 circuit breakers failed. The CVR cable failed 81 seconds after the alarm. The recording revealed the extent of the fire.
Van Zyl discovered that the front-right pallet was the seat of the fire. The manifest said that pallet mostly comprised computers in polystyrene packaging. The investigators said that the localised fire likely came in contact with the packaging and produced gases that accumulated near the ceiling. They also said that gases ignited into a flash fire that affected the entire cargo hold. The cargo fire of Flight 295 did not burn lower than one metre above the cargo floor. The walls and ceiling of the cargo hold received severe fire damage. Van Zyl ended his investigation without discovering why the fire started.
The official report noted the presence of the computer equipment, and suggested that a possible cause could have been the lithium batteries contained in the computers exploding or spontaneously combusting, although this was not given as a conclusive cause of the fire.
The official report determined that while the Helderberg was over the Indian Ocean, a fire had occurred in the cargo hold of the main deck, originating in the front right-hand cargo pallet. Aircraft parts recovered from the ocean floor showed fire damage sustained in temperatures over 300 °C (570 °F); tests showed that temperatures of 600 °C (1,100 °F) would have been required to melt a carbon-fibre tennis racket recovered from the crash site. The reason for the aircraft's loss was not identified beyond doubt, but there were two possibilities detailed in the official report: firstly, that the crew became incapacitated due to smoke penetrating into the cockpit; and secondly, that the fire weakened the structure so that the tail separated, leading to impact with the ocean. The commission concluded that it was not possible to apportion blame to any one individual for the fire, removing any terrorism concerns. The manufacturer is quoted in the report as having "contested" any scenario that involved a break-up of the aircraft, hence the commission went no further than simply mentioning the two possible scenarios in its final report, as incidental to the primary cause of the accident.
The commission determined that inadequate fire detection and suppression facilities in the class B cargo bays (the type used aboard the 747-200 Combi) were the primary cause of the aircraft's loss. The accident alerted aviation authorities worldwide to the fact that the regulations regarding class B cargo bays had lagged far behind the growth in their capacity. The exact source of ignition was never determined, but the report concluded that there was sufficient evidence to confirm that the fire had burned for some considerable time and that it might have caused structural damage.
The crash was the first fire incident on the 747 Combi and one of few fires on widebody aircraft. Fred Bereswill, the investigator from Boeing, characterised the Flight 295 fire as significant for this reason. Barry Strauch of the NTSB visited Boeing's headquarters to inquire about the Combi's design. Boeing's fire test in the Combi models did not accurately match the conditions of the Helderberg's cargo hold; in accordance with federal US rules, the Boeing test involved setting a bale of tobacco leaves ablaze. The fire stayed within the cargo hold. The air in the passenger cabin was designed to have a marginally higher pressure than cargo area hold, so if a crew member opened the door to the cargo hold, the air from the passenger cabin would flow into the cargo hold, stopping any smoke or gases from exiting through the door.
Investigators devised a new test involving a cargo hold with conditions similar to the conditions of Flight 295; the plastic covers and extra pallets provided fuel for the fire, which would spread quickly before generating enough smoke to activate smoke alarms. The hotter flame achieved in the new test heated the air in the cargo hold. This heated air had a higher pressure than normal, and overcame the pressure differential between the cargo hold and the passenger cabin. When the door between the passenger and cargo holds was open, smoke and gases therefore flowed into the passenger cabin.
The test as well as evidence from the accident site proved to the investigators that the 747 Combi's use of a class B cargo hold did not provide enough fire protection to the passengers. The FAA confirmed this finding in 1993 with its own series of tests.
After the accident, South African Airways discontinued use of the Combi and the Federal Aviation Administration introduced new regulations in 1993 specifying that manual fire fighting must not be the primary means of fire suppression in the cargo compartment of the main deck. Complying with these new standards required weight increases, which made the 747 Combi no longer viable. Nevertheless, the Combi remained in the 747 product line up until 2002, when the last 747-400 Combi was delivered to KLM.
In January 1992, the journal of the Royal Aeronautical Society (RAeS) reported that the inquiry into the in-flight fire that destroyed SAA Flight 295 might be reopened because the airline had allegedly confirmed that its passenger jets had carried cargo for Armscor, a South African arms agency. The RAeS journal, Aerospace, asserted: "It is known that the crew and passengers were overcome by a main deck cargo fire, and the ignition of missile rocket fuel is one cause now under suspicion." A complaint against the newspaper that first published the allegations, Weekend Star, was lodged by Armscor.
But the inquiry was not reopened, and this might be why a number of conspiracy theories were spawned concerning the nature of the cargo that caused the fire, which subsequently increased public doubts about the outcome of the initial inquiry. Examples of such theories include:
A South African government chemist examined a microscopic particle on the nylon netting next to the front-right pallet on Flight 295. The chemist found that the airflow patterns on the iron suggested that it travelled at a high velocity while in a molten state; therefore the fire on Flight 295 may have not been a flash fire triggered by packaging. Fred Bereswill, the investigator from Boeing, said that this would suggest that the source of the fire would have had properties like a sparkler, with the source including its own oxidising agent. A British fire and explosion analyst examined the exterior skin of the aircraft which had been located above the pallet; the analyst found that the skin became as hot as 300 degrees Celsius. Bereswill said that it would be difficult for a fire to burn through the skin of an aircraft in-flight because of the cool airflow outside the aircraft.
Dr David Klatzow was one of the forensic scientists who, by his own admission, was retained to work on the case by Boeing's counsel around the time of the official enquiry. He subsequently criticised the Margo commission for spending an inordinate amount of time looking into "relatively irrelevant issues" and that the commission ignored the most important question: what was the source of the fire and who had been responsible for loading it onto the aircraft. Klatzow believes that there are certain irregularities in parts of the commission transcript that indicate that something on the CVR transcript had to be concealed.
Klatzow put forward a theory that the fire likely involved substances that would not normally be carried on a passenger aircraft and that the fire was not likely a wood, cardboard, or plastic fire. South Africa was under an arms embargo at the time; the South African government therefore had to buy arms clandestinely. His theory postulates that the South African government placed a rocket system in the cargo hold, and that vibration caused unstable ammonium perchlorate to ignite, which is a chemical compound used as a missile propellant.
Klatzow contends that conversation of the crew suggests that the fire started above the South China Sea, shortly after takeoff; he believes that this indicates that the voice recorder was not working for a long period of the flight or that the crew turned it off (Cockpit Voice Recorders in aircraft at that time only recorded 30 minutes ). If this is the case, he says it is then likely that an unknown number of the passengers would have already died from smoke inhalation from the first fire. Klatzow believes that theory is consistent with reports that find most of the passengers were in the first class area at the front of the aircraft as smoke from the rear cabin forced them to move forward. The captain did not land the aircraft directly after the fire, Klatzow argues, because if he had he would have been arrested for endangering the lives of his passengers and it would have caused a major problem for South Africa, costing the country and SAA R400 million. Klatzow argues that the captain, who was also a reservist in the South African Air Force, would therefore have been ordered to carry on to South Africa in hopes of making it there before the aircraft's structural integrity gave in. These points have been refuted by others.
On 20 July 2011, retired SAA captain Clair Fichardt announced that he had made a statement in connection with the missing Jan Smuts air traffic control tapes, after he was persuaded to do so by Klatzow. Fichardt claimed that captain James Deale admitted to handing the tapes to captain Mickey Mitchell, who was chief pilot at the Johannesburg control centre on the night of the crash. Deale would further have stated that Gert van der Veer, head of SAA, and lawyer Ardie Malherbe were present during the transfer of the tapes. Earlier, during the TRC hearings, Klatzow had cross-examined Van der Veer, Mitchell and Vernon Nadel, the Operations Officer who was on duty.
In 1996, the Truth and Reconciliation Commission (TRC), established by the post-apartheid South African Government, investigated apartheid era atrocities. In particular, the Helderberg accident was investigated to determine if there was any truth behind conspiracy theories that asserted that the Margo Commission had covered up or missed any evidence that might implicate the previous government. David Klatzow was invited by the TRC to explain his theories and cross-examine witnesses. Unlike most other hearings of the TRC, the hearing into SA 295 was conducted in camera, and without any representation from the South African Civil Aviation Authority (CAA); Klatzow considered the CAA untrustworthy because it had participated in the official enquiry, which he considered flawed. A number of key aspects of Klatzow's theory hinged on his criticism of the actions of Judge Margo during the official enquiry, yet Judge Margo was not summoned to answer any of the allegations made against him.
The commission concluded that nothing listed in the cargo manifest could have caused the fire. Following public pressure, the TRC records were released into the public domain in May 2000. Upon receiving the documents, Transport Minister Dullah Omar stated that the inquiry would be reopened if any fresh evidence was discovered. The police were tasked to investigate whether there was any new evidence, and to make a recommendation to the minister. In October 2002, the minister announced that no new evidence had been found to justify re-opening the enquiry.
On the 25th anniversary of the crash, Peter Otzen Jnr, the son of one of the victims, announced that he was approaching the South African Constitutional Court in an attempt to have the commission of inquiry into the disaster reopened. In pursuit of this, he has obtained affidavits from former SAA employees who had never before given evidence. An Australian, Allan Dexter, had given a sworn statement to Mr. Otzen claiming that he had been informed by the SAA Manager at Taipei airport that the Helderberg was carrying rocket fuel, which caused it to crash.
In 2014, the South African investigative journalist Mark D. Young presented a theory that a short circuit in the onboard electronics may have caused the fire. The so-called wet arc tracking arises from the action of moisture when the insulation of live wires is damaged. A leakage current to another damaged wire with the respective potential difference may form. The resulting flashover may reach temperatures of up to 5,000 °C (9,000 °F). This temperature is sufficient to ignite the thermal-acoustic insulation blankets that were still used until the late 1990s. Such a short circuit caused the fire on board Swissair Flight 111, resulting in the crash of the aircraft in 1998.
Passengers and crew nationalities on board SAA Flight 295:
Taiwanese authorities stated that 58 passengers began flying in Taipei, including 30 Taiwanese citizens, 19 South Africans, 3 Japanese, two Mauritians, one Dane, one Netherlander, one Briton, and one West German. The other passengers transferred from other flights arriving in Taipei, and as such their nationalities were not known to Taiwanese authorities.
At least two passengers died of smoke inhalation. The rest died from the extreme trauma sustained in the crash.
Thomas Barry Osler, South Africa's chief oil sanctions buster was also on the flight. The omission of his name from the passenger manifest meant that the media did not pick up on his presence for at least a decade after the crash. Osler was a director of the Industrial Development Corporation. The first evidence and public acknowledgement of his presence on board the plane is in the now publicly accessible 500-page transcript of the TRC's closed-door hearing into the disaster. During examination, led by the investigators, Patten, Terreblanche, and Klatzow, Armscor's John Hare was asked about the possible links between Osler and Armscor. Hare was a long-time director of Armscor and a senior manager in its finance department, who subsequently worked for SAA. Hare confirmed that Osler 'provided assistance to Armscor on a consultative basis, regarding a transaction that Armscor was interested in." Hare told the TRC that this was on a 'one-off basis' and was linked to the export of material by Armscor.