Report of the Board of Inquiry into the Helderberg air disaster/Foreword and Synopsis
The Hon The Minister of Transport and of Public Works and Land Affairs
Pretoria
Sir
We have the honour to submit herewith the final Report of the Board of Inquiry into the loss of South African Airways Boeing 747 – 244B Combi aircraft "Helderberg" in the Indian Ocean on November 28th 1987.
Our Report is unanimous.
| C S Margo (Chairman) | Y Funatsu |
| H Goburdhun | J J S Germishuys |
| George N Tompkins Jnr | James Gilliland |
| G C Wilkinson | Liang Lung |
Paragraph 6.11 of Annex 13 of the Convention on Civil Aviation
Pursuant to paragraph 6.11 of Annex 13 to the Chicago Convention, the United States of America, as the State of manufacture, was invited to submit comments on the draft Final Report of the Board. Dr Barry Strauch, the U.S. Accredited Representative, submitted comments to the Board on behalf of the National Transportation Safety Board (NTSB) of the United States. Dr Strauch also forwarded to the Board separate and independent comments of the Federal Aviation Administration, the airworthiness authority of the United States, and The Boeing Company, the manufacturer of the aircraft. These comments have been given full consideration by the Board in the preparation of this Final Report.
The comments of the NTSB as contained in its letter of March 9, 1990 are annexed hereto as Appendix J. See Volume 2 pp 85–86.
Foreword
The Board of Inquiry extends its profound sympathy to the families and friends of the passengers and crew who lost their lives in the Helderberg accident.
The Board believes that all concerned would wish to join it in this expression of gratitude to the Mauritian, French, United States and Australian authorities (named in paragraph 1.15 page below) for their humanitarian response and participation in the search and rescue operations.
The Board places on record its appreciation of the outstanding services of Mr R W van Zyl, the Director of Aviation Safety in the Chief Directorate of Civil Aviation, Department of Transport, and of his technical investlgation team, consisting of himself, Mr P de Klerk, Capt R Downes and Mr B Jordaan. In particular, Mr van Zyl's direction of the underwater search is to be highly commended. That search, known as Operation Resolve, was carried out at depths of the order of 4,5 km, and represents a remarkable and pioneering technological achievement.
The Board also wishes to record its appreciation of the valuable guidance and information given by the United States Federal Aviation Administration (FAA) representatives who assisted the technical investigation team and who attended the public hearings. They were Messrs Harold Donner, Richard Hill, and Wes Slifer.
Of great importance to the investigation at all stages was the the assistance and ready co-operation of South African Airways, which, through Mr Albert Boshoff, assisted by Mr J Prozesky, Mr T Kruger, Mr T Perfect and other technical personnel, played a vital role in organizing and conducting Operation Resolve, and in carrying out numerous other important investigations and tests.
The Board is likewise indebted to The Boeing Company for its unhesitating response to the innumerable requests for assistance and for the mass of technical information furnished from time to time.
Also deserving of the Board's appreciation are the S A Bureau of Standards, Capt A D van Heerden, who represented the International Federation of Airline Pilots Associations, and the counsel and attorneys who appeared at the hearings to represent interested parties. They were Mr B R Southwood, SC, with him Mr R W Nugent, instructed by Mr J N J van Rensburg, of Rooth & Wessels, Pretoria, who acted for the Board in presenting the evidence (Mr van Rensburg also acted as the Board's attorney); Mr S A Cilliers, SC, with him Mr L Bowman, instructed by Mr D E Jooste, of Bowman, Gilfillan, Hayman, Godfrey Inc., Johannesburg, and Mr Rex Browning of Attorneys Perkins, Cole, of Seattle, USA, for The Boeing Company; Mr C E Puckrin, SC, with him Mr C M Eloff, instructed by Mr P D de Wet, of Bowens, Johannesburg, and Solicitors Barlow, Lyde & Gilbert, London, for South African Airways; and Mr D M Antrobus, instructed by Mr P Naude, of Deneys Reitz, Johannesburg, and by Mr P Kemp, of Kemp Evenhuis, Johannesburg, for the widows of two of the passengers.
Recognition must also be given to the contribution by of way of technical expertise made by Mr Toru Tatebe, of All Nippon Airways, and Dr Bang-Lee Ho, of the Aviation Medical Centre, Civil Aeronautics Administration, Republic of China.
The Board conducted its proceedings in public at Johannesburg on 15th, 16th, 17th, 18th, 22nd, 23rd, 24th and 25th August 1989. This was after notice had been given and advertisements placed of the date and place of the hearings and of the right of all interested parties to appear before the Board in person or via authorized representatives, to cross-examine witnesses, to call their own evidence and to make submissions to the Board. The United States National Transportation Safety Board (the NTSB), as representing the State of Manufacture, was specially invited to send representatives to the hearings, but notified the Board that it was unable to do so because of its numerous other commitments and shortage of available personnel. It pointed out, however, that there would be representatives of the FAA present, to whom the Board could turn for advice and information.
In addition to the public hearings, the Board, during March 1988, conducted inspections of a Boeing 747-244B Combi aircraft at Jan Smuts Airport, and viewed demonstrations of fire fighting equipment and procedures. The Board also inspected, during August 1989, the wreckage assembled in the "Debris Hanger" at Jan Smuts Airport, and it viewed the more important of the more than 3 000 photographs of the wreckage on the sea-bed taken in Operation Resolve, and certain of the more than 800 hours of video tapes of some aspects of the underwater operations. The Board also received and considered numerous reports of fires in aircraft, and a great deal of documentation from ICAO, IATA, various airlines, pilots' associations and the statements of numerous experts which had been obtained by the technical investigation team in the course of assembling the data placed before the Board at the public hearings. Also investigated and considered were numerous communications from members of the public, particularly on their experiences of spontaneous fires in various types of goods.
Some explanation is warranted of the time taken since the accident to reach the stage of public hearings. As Mr van Zyl stated in his testimony, "We have spent thousands and thousands of hours on the Helderberg investigation". The fruitless search for pinger signals and thereafter the prolonged search for the wreckage of the aircraft were followed by extensive efforts to find a suitable contractor for the endeavours to reach the wreckage and to lift selected portions thereof. In the then state of the art this was a difficult and lengthy operation which necessitated obtaining the required information and advice, working from scratch, negotiating a suitable contract and making the required provision for personnel, organization, auxiliary and support services and finance. Considerable time was also involved in the contractor's preparations, which included the manufacture of 22 000 feet of specially designed cable. Eventually, after much time, Operation Resolve got under way, only to be delayed repeatedly by cable failures, necessitating more often than not a return to port in Mauritius, and by unfavourable weather. Meanwhile, as evidence was gradually being accumulated, more and yet more scientific and technical research and testing were called for. In particular, after the recovery of the cockpit voice recorder (CVR) and selected items of wreckage, the work of identifying and assembling as much of the wreckage as possible, and of analyzing and evaluating the metallurgical, chemical and other signs, had to be pursued painstakingly and thoroughly.
In the event the time taken up was more than justified.
Aircraft Accident Report
Operator and Owner : South African Airways
Aircraft : Boeing 747-224B "Combi" - Serial No. 22171
Nationality : South African
Registration : ZS-SAS
| Place of Accident : | In the Indian Ocean 134 nautical miles North-East of Plaisance Airport, Mauritius. |
| Date and Time of Accident : | November 28th 1987, at approximately 00:07:00 |
| Note: | Save where otherwise expressly indicated all times stated in this report are in Co-ordinated Universal Time (UTC). |
Synopsis
On November 27th 1987 at 14:23, flight SA 295, a Boeing 747-244B Combi of South African Airways, departed from Taipei's Chiang Kai Shek Airport for Mauritius' Plaisance Airport with 159 persons on board. In the main deck cargo hold 6 pallets of cargo had been loaded. Some 9 hours out and some 46 minutes before the estimated time of arrival at Plaisance the flight deck informed the approach control at Plaisance that there was a smoke problem in the aeroplane and that an emergency descent to flight level (FL) 140 had been initiated. The last radio communication was at 00:04 on November 28th 1987. At about 00:07 the aeroplane crashed into the sea. The wreckage, consisting of thousands of fragments, sank to the ocean bottom at depths of the order of 15 000 feet (about 4,5 kilometers), although many of the lighter materials floated away on the currents. Some of the latter items were recovered from the sea, or from the sea-shores where they had been washed up far from the scene of the crash. Months later one such item was found on a beach in Natal, over 2 000 nautical miles away. There are clear indications that a fire developed in the right hand front pallet in the main deck cargo hold, that the fire got out of control and that it eventually led to the crash.
There were no survivors.
The State of Registry, the Republic of South Africa (RSA), was notified of the accident by Plaisance Air Traffic Control (Mauritius) at 01:15 on November 28th 1987.
As the accident had occurred outside the territory of any State, the investigation of the accident was conducted by the State of Registry in terms of paragraph 5.3 of Annex 13 to the Convention on International Civil Aviation. This was agreed to by the Government of Mauritius.
The State of Manufacture of the aircraft, the United States of America (USA), was notified of the accident on November 30th 1987 at 08:10 and was requested to participate in the investigation, in response to which request an accredited representative was appointed from the NTSB. The accredited representative was accompanied by representatives of the FAA and The Boeing Company respectively. All the representatives had full access to all the phases of the investigation and all the available information. They were most helpful and co-operated fully with the investigator-in-charge.
The Operator provided advisers and all possible assistance and logistic support needed in all the phases of the investigation. It also had full access to all available information. Full co-operation was given to the investigator-in-charge.
The representatives of the Operator, The Boeing Company and the NTSB, undertook to provide the investigator-in-charge with all the available information that might be required for the investigation of the accident. The investigator-in-charge provided the factual report to the representatives of the participating parties for information and comments.
The State conducting the investigation (RSA) appointed an Accident Inquiry Board in terms of section 12(1) of the Aviation Act 74 of 1962. The Board comprised one member from each of the States of Japan, the Republic of China, Mauritius, the UK and the USA, and three members, including the Chairman, from the RSA. The members from Japan, the Republic of China and Mauritius, were appointed by their respective governments. The members of the Board, by name, were Mr Justice C S Margo, DSO, DFC, FRAeS, of the RSA, (Chairman), Mr Justice H Goburdhun, of Mauritius, Mr George N Tompkins Junior, of the USA, Mr G C Wilkinson, CBE, FRAeS, of the UK, Dr Y Funatsu, of ANA, Japan, Mr J J S Germishuys, of the RSA, Dr J Gilliland, of the RSA, and Colonel Liang Lung, of the Republic of China.