Fe

|
|

During the plane's slide across open ground,
(Fig, 2) the landing gears were torn completely
off and as the aircraft slid up over the two-foot
high edge of the concrete taxi strip, three of
the four engines tore free ~ small fuel fires
immediately erupted near and below the for-
ward portion of the aircraft, where several of
the engines had come to rest.

Evidence indicates that decclerative forces
were extremely low throughout the -ccident,
and no impact injuries of any consequence
occurred within the aircraft.

Soon after the aircraft came to rest, two
major fire areas developed. One was near an
engine in front of the right wing: this fire,
following fuel on the ground, soon traveled to
the forward righthand portion of the fuselage.
The other major fire was concentrated at the

left. wing root, within which the number I
engine had become lodged.

The three airport fire trucks reportedly
reached the aircraft within 1 to 2 minutes
after impact and were driven to an area near
the right side of the aircraft, from which point
the firemen vainly attempted to control the
fire.

However, prior to arrival of the fire trucks
and immediately after the aircraft came to rest.
the cockpit crew and the stewardesses in the
forward -(First Class) cabin opened the for-
ward, lefthand passenger dvor and deployed
the evacuation chute; the chu was not inflated
due to the short: distance {appreximately 4.5
feet) between the doorsill and the ground.

The service door on the opposite (righthan¢)
side of the cabin was not opened by the crew,
because of the large fire near this exit.

Fron 2


this non-burning could have oni. ‘2sulted from
protection of the seat covering py portions o1
‘he occupants’ bodies, as indicated in Fig. §
by the subject simulating a body in a slumped
position. .

Frevne 9. +

Another exampte of this non-buming is shown
in Fig. 10, in which the egnter armrest is almost
completely miburned, and the fabric on a por-
tion of the backrest is not even singed. An out-
line of the ocefipants Jeft elbow and a pertion
of the forearm can‘: seen in the aisle armrest,

“‘Beveral seats were ti pped; out_of the cabin
by rescue personnel (a “jm fire had been

extinguished) and) were,/found outside the
wreckage. Portions of the. seat cushion, the
seatbelt, and a part of the armr ppert on
one of these seats were unburned: in the seat
was a ladies’ jacket (Fig, 11), which the occu-
parently had beow sitting on dnring the
. A picoe of floor k owas found still
ached to the seat pin (Fig, 12), effectively
pin pointing the original — seated — location of
one of the victims in this accident (Fig. 13).

Ficens 10,

Fane U1,

-§-


Foie 4



:

Evidence indicates that 26 of the 36 first
class passengers and all five of the forward
vrew members utilized the lefthand passenger
door for escape, despite the increasing magni-
tude of the fire at the left wing root, which
eventually consumed a major portion of the
aircraft before the fire was finally brought
under control (Fig. 3).

The two righthand over-wing exits were
reportedly opene? by several passengers, and
were ntilized by approximately nine of the first
class passengers and eleven adults and a-child
from the forward part of the tourist cabin,

Since the fire was quite intense at the’ left
wing root, it is doubtful that the lefthand over-
wing exits were opened,

In the rear (Tourist) section of the aircraft,
one of the two stewardesses was sitting in the
lounge; the other, wearing her shoulder har-
ness and seatbelt, sat on a crew seat directly
adjacent to.the rear, lefthand, passenger door.
As the aircraft slid sideways to a stop, parapher-
nalia (pillows, magazines, and other passenger
comfort items) was ejected from an upper
storage locker on the righthand side of the air-
craft and deposited in a pile* nee deep” against
the passenger door. Due to the debris piled
up against the door, the stewardess did not
attempt to open it; however, due to structural
deformation of the fuselage under the door
resulting from impact with the panel truck
(Fig, 4}, the door could not have been opened
by the stewardess,

Fete ot.


window exits available within the tourist cabin,
(3) a floor-to-ceiling partition separated the
tourist cabin from the first class section, effec-
tively blocking from the view of the tourist
Passengers any sight or sign of the over-wing
exits available in the first class cabin, and (4)
there was no placard or indication on the aft
side of the partition to indicate the existence
and availability of emergency exits in the first
class cabin.
During the routine CARI investigation of this
. accident, in cooperation with the Civil Aero-
nautics Board, it was determined that. the
persons, who had succumbed from. ‘carbon
monoxide poisoning while attempting to evac-
uate the tourist section, died in the seats shown
in the lower portion of Fig. 7; these were not
the seats for which they had heen ticketed.
It is of interest that these seats in which they
died are predominantly spaced at random along
the aisle. This indicates that these persons
must have left their own seats and were
attempting to move down the aisle toward the

rear exit when they were overcome; it may be .

assumed that they’ collapsed into, or sat down
in these seats to try to regain their senses and
to await clearing of the aisle.

Determination of the seats in which these
persons died was accomplished by detailed in-
vestigation at the scene of the accident during
which evidence was obtained indicating where
the occupants most likely were sitting when
they were asphixiated and subsequently burned
in the post crash fire.

A portion of this evidence was obtained by
noting unburned areas on ihe covering of back-
rests and armrests of numerous seats (Fig. 8);



ea-4

7 ey ASTIA

CATA Aar

OL 2-7

EVACUATION #ATTERN
ANALYSIS OF A SURVIVABLE
COMMERCIAL AIR“2AFT CRASH

YY Lippi

62-9

FEDERAL AVIATION AGENCY
Aviation Medical Service
Research Division
Civil Aeromedical Research Institute
Protection and Survival Branch
Oklahona City, Oklahoma

‘

/ - MAY, 1962



In addition:

{7) No’ emergency evacuation instruction
_ was given the passengers prior to the incident.
-(8) The available fire-fightin equipment
was unable to contain or control the post crash
fire within the required time

RECOMMENDATIONS
It is recommended that:

(1) Prior to any anticipated, unusual landing
situation — in which emergency evacuation
might be necessary — the passengers be in-
structed in emergency evacuation procedures.

(2) Aisle widths in high density cabin areas
be re-evaluated through a comprehensive re-
search program in ‘which evacuation time is
related to impaired breathing and sight as may
occur in a post crash fire situation,

(3) Placards or other appropriate means be
utilized in transport cabins to acquaint all pas-
sengers with the location of emergency exits
in other — distant — areas of the aircraft. -

(4) Effective means be found through fur-
ther research to contain and control post crash
fires occurring on airports,

(5) Research be conducted on means of pro-
‘ viding passengers with yncontaminated breath-
4 ing air for time periods sufficient to evacuate
: a During airéraft.

, (6) Requirements and regulations govern-
jng the number and location, of exits in trans-
ort aircraft he re-evaluated in relation to
‘ aisle width, passenger capacity and cabin

compartmentation,

my

\

PAA AC 08220 ~10—


The upper portion of Fig, 7 shows the
assumed eration of the fatally burned persons,
according to the recollections and statements of
reste personnel given during the official hear-
ing several w Es after the accident, The
variation between the location of the fatally
injured persons, according to the memory of
rescue personnel, as compared to the locations
determined by findings of experienced investi-
gaors at the scene of the accident (as shown
in the lower portion of Fig. 7), is easily appar-
ent; this would appear to indicate that infor-
mation obtained from witnesses who have been
involved in a psychologically shocking experi-
ence — such as the removal of human bodies
from an aircraft — should be treated with ut-
most caution,

SUMMARY

(1) Sixteen passengers died of carbon mon-
a7 oxide poisoning while attempting to evacuate
an intact, modern jet transport that had been
involved in a low force accident; a post crash
fuel fire outside the aircraft generated a large
volume of dense smoke and noxious fumes
which were funneled through the passenger
cabin as soon as the exits were opened.

(2) These sixteen passengers along with 65
other persons, occupied a cabin area in which
aisle width was minimal and only one door exit
was available — at the extreme rear of the
compartment.

(3) There was no placard or other sign in
this compartment indicating the existence of
emergency exits in the fenvard (First Class)
section.

(4) Tt was virtually impossible, due to the
narrow aisle width, for cabin attendants in the
tonrist ion te go forward and accelerate
the p gers Yow the rear exit,

Tn contrast to this:

‘y
(5) The first class cabin had three exits
available forjuse by only forty-one occupants.

(6) aisle width was approximately 404
.

Frecnr 13. xreater than that in the tourist section,

-~9-


fe

The other stewasdess (who had been sitting
in. the lounge) opened the rear, righthand serv-
ice door, ed the escape chute in position,

inflated it, and then started assisting the tourict
passengers throv-gh this exit (Fig. 5).

Ficvne 5.

It is noteworthy that as soon as the doors and
exits were opened, dense smoke began to funnel
back through the entire cabin, making sight
and breathing extremely difficult. It is also
noteworthy (according to survivor statements )
that there was little or no hysteria; in fact,
there apparently was a remarkably degree of
cahuness: displayed by most, if not all of the
occupants,

Distribution of the occupayts of the aircraft
in relation to thetnumber of ‘exits utilized pro-

Fenn &

vides an interesting picture (Fig. 6 — it was
impossible, due to legal complications, to obtain
information from some of the survivors and
therefore, the seating diagram fs not complete).
There were thirty-six passengers and five crew
members in the forward cabin-cockpit area;
three exits were available in this accident for
evacuation of these forty-one persons — a ratio
of one exit for each 14 persons.

Seventy-nine passengers and two crew mem-
bers occupied the tourist compartment, for
which there was only one exit (a service door)
available for evacuation. All of the fatalities
were in this rear. compartment, whose ratio of
exit to occupants was 1:81, as compared to
1:14 in the forward compartment.

As noted before, as many as 12 to 14 persons

ii,- tourist cabir apparently went forward
and used U.+ exits available in the first class
cabin. If these fourteen persons (including
one infant in arms) did use the forward exits,
the remaining sixty-seven persons apparently
attempted to use the only other exit available
in the aircraft — in the rear — but only fifty-one
were successful.

In attempting to. determine why all of these
sixty-seven tourist papense's were unable to
evacuate the aircraft through this one exit, sev-
eral major factors bear scrutiny; (1) the width
of the aisle between the rows of triple seats in
the tourist section was 15.5 inches, or approxi-
two thirds of the 22 inch aisle width in
class section. This narrow aisle width
in the tourist cabin would require that: the
evacuating passengers stand in single file, while
waiting to move toward the exit at the rear of
the aircraft, (2) there were no over-wing or



THE ACCIDENT

Prior to landing at Denver, an apparent mal-
function of the plane’s hydraulic system oc-
curred and the captain declared an “alert”;
three pieces of emergency fire-fighting equip-
ment at the airport were immediately driven
to and stationed near the far end of the in-
tended runway.

Aboard the aircraft, passengers were notified
of che situation by the captain, but were
reassured that the landing would probably in-
volve nothing more than perhaps a “hard”
tonchdown,

Insofar as can be determined, no emergency
evacuation instruction was given the passengers

by any of ihe crew members prior to the
fending.

According to witnesses, the plane touched
down normally within fifteen hundred feet of
the rear end the runway and proceeded
yn the rensvay in a straight line for several
ved feet, before it began to veer off to the
right. As it skidded off the runway, it grad-
ually vawed to the right and slid almost side-
ways across open ground, striking a panel truck
— Filng the driver. “Toward the end of this
gradual deceleration, the aircraTM ‘ruck the
sheer edge of an incompleted taxiway, on which
the aircraft fi.auy came to rest (Fig. 1).

STAPLETON AIRFIELD

() DENVER, COLORADO
~
2 . .

~ Ww

ti
i ha a
a” zx

LL errr 4

Fine 1



EVACUATION PATTERN ANALYSIS OF
A SURVIVABLE COMMERCIAL AIRCRAFT CRASH

A. HOWARD HASBROOK

J. D. GAR

B

CLYDE C. SNOW

ABSTRACT

vacuition patterns of 9
crash fire is described, factors possi

ivor of a jet transport crash involving a post
ing the suffocation and ultimate death of 16

pawengers are listed and photography and diagrams are presented,

FOREWORD

The data from which this preliminary report
s developed was gathered through — the
cooperative efforts of many persons and groups
in the aviation safety field — investigation per-
sonnel of the Civil Aeronautics Board, Flight
Standards: Division (FAA), Aviation Medical
ion (FAA), Civil
Institute (FAA), United Airli
craft Company and inany others,

in the Civil Acfomedical Research Insti-
tute, research persohnel of the Emergency
Evacuation, Sur 1 Equipment, Physi
Anthropalogy and Crash Safety Sections
Protection and) Survival: Branch, ‘and photo-
graphers in the Audio-Visual Service, combined
their efforts as a team to investigate and ana-
lyze the results of this transport accident, With-
ont this team effort and the nce and
cooperation of other agencies and persorinel this
report could not have been prepared.

Nore: Major portions of this report were presented under
the same title at the 33nd annual meeting Ri the Aerospace
Medical Aswviation at) Atlantic City, New Jerey on
April 10, 1962.

INTRODUCTION

In the past, the aviation ind:
airline ope
Aper 5 i
im of providing rapid”

ft, particularly i
compartments.

Why then, did sixteen of 122 occupants of a
modern ‘jet airliner perish while attempting to
evacuate a virtually intact — but smoke filled —

pre minary report
vere apparently related to the
tem (developed through re
ysis), the methods of aetermining the
nof the deceased pi
Fecommnends areas which appear to require
further consideration and/or r search in relation
to preventing similar occurrences in post crash
fires, .



EVACUATION PATTERN ANALYSIS OF
A SURVIVABLE COMMERCIAL AIRCRAFT CRASH

A. HOWARD HASBROOK
Chief. Crash Safety

J. D. GARMER

Acting Chief, Emergency Escape

CLYDE C. SNOW

Physice? Anthrapoloty

62-9

Vo FEDERAL AVIAJION AGENGY
Aviation Medical Service
Revearch Division
Civil, Acromedtical Research Institute
‘Protection and Surviv Branch
Oklshunon City, Oktahorne

May 1962