Report of the Board of Inquiry into the Helderberg air disaster

by Cecil Margo et. al.

Report of the Board of Inquiry into the Loss of South African Airways Boeing 747 - 224B Combi Aircraft "Helderberg" in the Indian Ocean on November 28th 1987

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Chairman

The Hon. Mr Justice C S Margo

[South Africa]

Board Members

Mr G N Tompkins, Jr	[United States of America]
Mr G C Wilkinson	[United Kingdom]
The Hon. Mr Justice H Goburdhun	[Mauritius]
Dr Y Funatsu	[Japan]
Mr L Lung	[Republic of China]
Dr J Gilliland	[South Africa]
Mr J J S Germishuys	[South Africa]

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Table of Contents

Volume 1			Page
Letter to Minister Submitting Report				1
Paragraph 6.11 of Annex 13 of the Convention on International Civil Aviation				2
Foreword			3 –	7
Aircraft Accident Report				8
Synopsis			8 –	11
1.	Factual Information		11 –	118
	1.1	History of Flight	11 –	16
	1.2	Injuries to Persons		16
	1.3	Damage to Aircraft		17
	1.4	Other Damage		17
	1.5	Personnel Information	17 –	24
	1.6	Aircraft Information	24 –	28
	1.7	Meteorological Information	28 –	29
	1.8	Aids to Navigation		29
	1.9	Communications	30 –	36
	1.10	Aerodrome Information	36 –	37
	1.11	Flight Recorders	37 –	42
	1.12	Wreckage and Impact Information	43 –	66
	1.13	Medical and Pathological Information	66 –	67
	1.14	Fire	67 –	77
	1.15	Survival Aspects and Search and Rescue	77 –	79
	1.16	Tests and Research	80 –	89
	1.17	Additional Information	89 –	110
	1.18	Useful or Effective Investigation Techniques	111 –	118
2.	Analysis		119 –	146
3.	The USA FAA's Response to the Helderberg Accident and the Board's Approach		146 –	170
4.	Findings and Conclusions		171 –	174
5.	Causal Factors and Responsibility			175
6.	Recommendations		175 –	178

Volume 2
Appendix "A"	—	Plan of wreckage distribution	1 –	5
Appendix "B"	—	Layout of interior of aircraft		6
Appendix "C"	—	Details of wreckage items including report of manufacturer of engines	7 –	17
Appendix "C"bis	—	Drawing of the lower aft fuselage structure (Target 244)		18
Appendix "D"	—	Emergency check lists	19 –	20
Appendix "E"	—	NTSB Safety Recommendations to FAA, May 16th 1988	21 –	24
Appendix "F"	—	FAA's "Evaluation of Transport Airplane Main Deck Cargo Compartment Fire Protection Certification Procedure"	25 –	51
Appendix "G"	—	FAA's NRPM, July 8th 1988	52 –	78
Appendix "H"	—	FAA's AD 89-18-12 R1, August 10th 1989	79 –	83
Appendix "I"	—	Oxygen supply selections		84
Appendix "J"	—	Comments of NTSB on Draft Final Report	85 –	86