Note: this accident was previously featured in episode 16 of the plane crash series on December 23rd, 2017, prior to the series’ arrival on Medium. This article is written without reference to and supersedes the original.
On the 11th of July 1991, a Canadian airliner packed with African pilgrims returning from Mecca burst into flames shortly after takeoff from Jeddah, Saudi Arabia. As the pilots rushed to land their burning DC-8, fire ripped through the cabin, turning the crowded aisles into a hellish death trap as hundreds of people tried to flee an inferno from which there could be no escape. Visibly aflame, the plane came in low over the city, disintegrating as it went, dropping charred bodies onto the streets of Jeddah. Moments later, flight 2120 ran out of time: within sight of the runway, the plane broke apart and crashed into the Arabian desert, killing all 261 passengers and crew.
An investigation by Canadian and Saudi authorities revealed that the devastating fire originated from a single underinflated tire, triggering a cascading sequence of events that brought down the plane. The investigation also revealed a series of miscommunications and errors of judgment in the days and hours leading up to the crash, as a ground support team with insufficient knowledge and experience worked to maintain the airline’s contractual obligations. But amid disturbing reports about its working culture and escalating disputes with its staff, Nationair Canada abruptly went bankrupt in 1993, leaving in its wake a trail of bitter memories, allegations of fraud, and 261 families who, thirty years later, still haven’t seen justice.
In 1984, Moroccan-born businessman Robert Obadia saw off the inaugural flight of his new airline, Nationair Canada, as it departed for the Dominican Republic. Based in Quebec and equipped with a fleet of two aging Douglas DC-8s, the airline promised to fill gaps in the Canadian air charter industry created by the demise of several airlines in the first half of the 1980s. The strategy of finding gaps and filling them, as opposed to competing with other airlines, proved a lucrative one: just seven years later, in 1991, Nationair had expanded its fleet to seven DC-8s, two Boeing 757s, and four Boeing 747s, and from 115 employees to more than 1,400. Passengers complained that its planes were unkempt, noisy, and uncomfortable, but safety didn’t seem to be in question, and profits continued to roll in despite its rapid expansion, earning the airline a Canadian entrepreneurship award in 1989.
As part of its strategy of finding and filling gaps in the industry, Nationair actively solicited short-term contracts abroad. In June of 1991, management became aware of an unusual opportunity: an airline which had been contracted to carry pilgrims on Hajj to Mecca had gone bankrupt, and a Saudi Arabian brokerage firm was urgently looking for another airline to carry its passengers. Most North American airlines would never have considered the offer, but Nationair did not shy away from a business opportunity. Within days, the company informed its chosen crews that for three weeks that summer, they would not be carrying Canadian tourists to the Caribbean, but African pilgrims to Mecca.
The Hajj is one of the world’s largest religious pilgrimages. According to the teachings of Islam, every Muslim with the physical and financial means to travel to Mecca, the birthplace of the Prophet Muhammad, must do so at least once in their lives. In centuries past, this rite was reserved for the very wealthy, but the advent of air travel fundamentally changed the nature of the pilgrimage, transforming it into a global event which draws more than two million people to Saudi Arabia every year during a narrow window lasting less than two months. To accommodate this influx of people, Saudi Arabia has invested billions of dollars in creating Hajj infrastructure, from Jeddah Airport’s enormous “Hajj terminal,” which can hold 80,000 pilgrims and contains its own mosque and open-air market, to less tangible contractual relationships with numerous airlines which bring in hundreds of thousands of people under a per-country quota system. But as Nationair would soon discover, the Hajj system, although massive in scale, was not exactly a well-oiled machine.
Nationair’s contract was with a Saudi Arabian firm called the Al-Rajhi International Trading Company, which was not an airline, but a broker which had been entrusted by the Saudi government to find alternative transportation for the pilgrims assigned to the defunct airline. A Nigerian company which held the right to transport a certain number of pilgrims then signed a contract with Al-Rajhi to secure the use of the Nationair DC-8. This company then signed another contract with Nigeria Airways, the flag carrier of Nigeria, in order to acquire that airline’s support services and the use of its callsign and branding.
In reality, however, most of the day-to-day operations would be Nationair’s responsibility. As such, Nationair supplied its own pilots, flight attendants, and maintenance staff, who traveled together aboard the DC-8 to Jeddah, the main port of entry for Hajj pilgrims, on the second of July. In charge of the maintenance team was Lead Mechanic J. P. Philippe, an ambitious French expat who had been chosen due to his previous experience working in Africa. Seeking a promotion and keen to impress his superiors, he had told the General Manager of Technair, Nationair’s wholly owned maintenance provider, that this would be “the smoothest [deployment] Technair would ever encounter.” Within days, he had called all his connections in West Africa and arranged to use their hangars and personnel. His managers were indeed impressed. Despite Philippe’s limited DC-8 experience and his rudimentary command of English, they were confident that they had made the right choice.
Philippe’s promises notwithstanding, the Hajj deployment did not get off to an auspicious start. After just a few days of flights, the plane’s weather radar malfunctioned, and the DC-8 sat grounded in Ghana for 33 hours while a replacement was flown in from overseas. Several flights’ worth of pilgrims had to be transferred to other carriers. The delay created a headache for another member of the Nationair team: Project Manager Aldo Tetamenti, whose job was to ensure that Nationair fulfilled its contractual obligations to Al-Rajhi. It was worth noting, as it would later become an important link in the chain of events, that Tetamenti did not appear to have read the contract very carefully.
That chain of events began on the 7th of July, while the plane was on the ground in Accra, Ghana. Because of the large amount of downtime following the weather radar failure, the maintenance team decided to begin a scheduled A-check, a series of routine inspections which must be conducted every 125 flight hours. The check wasn’t due for another 35 hours, but now seemed to be a good time to get started, and they could finish it later — a practice not approved by Transport Canada, but out here in Africa, who was going to notice or care?
One of the A-check inspection items called for the mechanics to check the pressure in all of the airplane’s tires. Using a pressure gauge, mechanics noted that the pressure in tires two and four on the main landing gear was about 20 psi below the minimum value. These values were recorded on the A-check sheet, but after that, something strange happened: no one actually inflated the tires. Available evidence fails to explain why this was not done right away, but it may have been because these tires were nearing the end of their service lives and were scheduled to be replaced in only three days’ time. Nevertheless, someone used a different color pen to write over the original notes, replacing “160 psi” with “180,” the nominal value, even though the tires had not been inflated. The mechanic who most likely made the alterations would later be unable to explain them, but investigators would theorize that he changed the numbers in advance, anticipating that the tires would be filled before the A-check was completed and the document signed by an engineer.
On July 10th, having completed several more flights, the aircraft arrived again in Accra, where it was scheduled to undergo a four-hour maintenance stop in order to replace the #1, #2, and #4 main landing gear wheels and tires. Lead Mechanic Philippe had previously arranged for the new wheels to be stored on the property of a local company based at the airport, but when the plane arrived and the mechanics set to work, they ran into a problem: the storage room containing the wheels and tires was locked, and nobody had the key. It took them the better part of two hours to find someone who could let them in.
But just as the mechanics were about to begin the work, the Operations Officer, who was with the aircraft in Accra, received an urgent fax from Project Manager Tetamenti. “RE: FLT TO SOKOTO,” it read, referring to their next flight out of Jeddah. “TOP URGENT. Pls do all possible to get back the A/C to Jed by 0800 Z GMT or 1100 LT Jed or we stand to loose [sic] a lot. Situation with Nigerian Airways critical they are giving our pax away due to delay. Do not let maint change wheels in Acc. If you have a chance call me ASAP.”
Operations Officer Mike Sparks, whose job description was very similar to that of Tetamenti, immediately met with the mechanics, including Lead Mechanic Philippe, and they collectively decided that the tire replacement could wait. If Nigeria Airways was threatening to send their pilgrims on other airlines, then any further delays could jeopardize the contract, and they had to get the plane to Jeddah immediately. A short time later, the DC-8 departed Accra with the wheels and tires in its cargo hold, destined for installation the following day in Sokoto, Nigeria. Little did they know that the plane would never reach this scheduled stopover.
At 14:05 local time, the DC-8 arrived at Jeddah’s King Abdulaziz International Airport and parked at the Hajj terminal. The plane was scheduled to leave again at 20:00, but as so often happened, the disorganized nature of Hajj operations kept pushing back their departure. Half way through refueling, it turned out that contractual obligations had not yet been paid to the fuel provider, forcing the flight to be delayed until midnight. Subsequently, major delays were encountered in passenger processing, as each passenger had to be processed individually rather than in their original group due to the different number of seats on the DC-8 versus the Lockheed L-1011 on which they had originally been booked. Rounding up all the passengers, getting them to present the correct documents, and figuring out which of them could fit on the DC-8 took so long that the departure was delayed again until 08:00 the next morning.
At 03:00, the wakeup call went out to the pilots who would fly the next leg from Jeddah to Sokoto, Nigeria. The crew was to consist of 47-year-old Captain William Allan, an experienced pilot who had worked at Nationair for two years following his retirement from a 28-year career in the military; 36-year-old First Officer Kent Davidge, who was nearly as experienced; and 46-year-old Flight Engineer Victor Fehr, who had also recently entered the civilian workforce after leaving the military. They would be joined by Lead Mechanic J. P. Philippe, Project Manager Aldo Tetamenti, nine flight attendants, and 247 passengers, all of them pilgrims from northwestern Nigeria returning home after completing the Hajj.
Shortly before 08:00, with the passengers already on board the plane, Lead Mechanic Philippe showed up on the ramp at the Hajj terminal and asked a local ramp agent whether they had any nitrogen to inflate the tires. Why he waited until only twenty minutes before departure to ask about the tire pressure is not clear — the most probable explanation was that he simply forgot until then. In any case, the ramp agent rushed to a nearby facility run by the Saudi Arabian Tourist Bureau and inquired as to the availability of nitrogen to pump up the tires. Unfortunately, there was none on hand: the nearest available nitrogen was at the Saudi Arabian Airlines maintenance facility on the opposite side of the airport, and it would probably take some time to procure it. He returned to the ramp to tell Philippe the bad news, but Philippe wasn’t there, apparently having already boarded the aircraft. Instead, he found Project Manager Tetamenti and informed him instead. Tetamenti told him to “forget it:” they weren’t going to delay the flight to pump up some tires, especially when the wheels and tires would be entirely replaced in a few hours when they arrived in Sokoto.
Minutes later, Flight Engineer Fehr signed off on the maintenance release, clearing the plane to fly, unaware that two of the main landing gear tires were below the minimum pressure required to be considered airworthy.
At 08:10, the DC-8, operating as Nigeria Airways flight 2120, pushed back from the ramp at the Hajj terminal and began taxiing toward runway 34L for takeoff. But underneath the passenger cabin, unseen by anyone, the clock was already ticking down toward disaster.
When an aircraft tire is underinflated, the weight of the aircraft will fall disproportionately on the properly inflated tire opposite it on the same axle. In the case of the Nationair DC-8, the #2 tire, located in the forward and inboard corner of the left main landing gear, had been running underinflated for several days, placing continued stress on the #1 tire opposite it whenever the plane was on the ground. Over time, this tire began to weaken as the extra stress led to repeated overheating. And as flight 2120 taxied for 11 minutes across the asphalt sea under the blazing Arabian sun, the tire started to heat up again — edging inexorably toward the point of failure.
At 08:27, with First Officer Davidge at the controls, flight 2120 began its takeoff roll on runway 34L. As it accelerated, the stress on the tires increased until the #1 wheel on the left main landing gear abruptly failed at a speed of 60 knots. In the cockpit, the pilots heard a muffled flapping sound and felt some minor vibrations.
“What’s that?” Flight Engineer Fehr asked.
“We got a flat tire, you figure?” First Officer Davidge suggested.
Captain Allan’s first thought appears to have been that Davidge was somehow responsible. “You’re not leaning on the brakes, eh?” he said.
“No, I’m not,” said Davidge. “I got my feet on the bottom of the rudder.”
The plane continued to accelerate, reaching 80 knots, then ninety. Finally, 45 seconds into the takeoff roll, and thirty seconds after the tire failure, it reached V1, or decision speed, the last point at which they could reject the takeoff. According to Nationair procedures, only Captain Allan could have made the call to reject, but he didn’t seem worried.
“Sort of a shimmy, like if you’re riding on one of those, uh, thingamajigs,” Flight Engineer Fehr commented.
“Rotate,” said Allan.
First Officer Davidge pulled back to raise the nose. Moments later, the DC-8 left the ground and climbed away into the bright blue sky. The vibrations immediately vanished.
“Positive rate,” Allan called out.
“Gear up,” Davidge instructed. Captain Allan reached out and pushed the gear lever to the “up” position. He could not have known that from that precise moment, everyone on board was doomed.
It turned out that as the plane sped down the runway, the deflated tire had ripped away until the bare metal rim was dragging directly along the asphalt in a shower of sparks. Friction caused the metal to heat to enormous temperatures, quickly setting fire to adjacent tires. By the time the DC-8 lifted off the runway, witnesses on the ground could already see that its landing gear was on fire, but there was nothing they could do to warn the pilots. Unaware of the nascent blaze, the crew retracted the landing gear, bringing the fire inside the airplane.
For the next two minutes, the flight continued almost as normal. But as the pilots configured the plane and communicated with ATC, the fire grew unchecked inside the left wheel well, consuming tires, brackets, and other combustible materials. Nearby hydraulic lines started to break, releasing flammable hydraulic fluid that further accelerated the blaze. The spray of burning hydraulic fluid then acted like a blowtorch, punching holes in the surrounding fuselage. The situation was rapidly spiraling out of control.
At 08:30, still unaware of the fire, Flight Engineer Fehr spotted something that caught his eye. “You’ve got four low pressure lights,” he suddenly said. “We might be losing pressurization.”
“Okay, it’s not press…” someone started to say.
“Pressurization is uncontrollable,” Fehr said.
“Level off,” Allan ordered. Keying his mic, he said to ATC, “Nationair 2120, we’d like to just level off at 2,000 feet if that’s okay, we’re having a slight pressurization problem.”
Coincidentally, flight 2120 was not the only plane reporting a pressurization problem at that very moment — Saudi Arabian Airlines flight 738, which took off ten minutes before flight 2120, had the exact same issue. Having failed to use the callsign “Nigerian,” Captain Allan caused the controller to confuse the two flights for the next several minutes, during which he gave the stricken DC-8 instructions intended for the Saudi jet. In the first such transmission, he told the plane to descend to 3,000 feet, even though it was only at 2,000 feet — now everyone was confused.
Meanwhile in the wheel well, the blaze burned through the wall and breached the center fuel tank, literally adding fuel to the fire. The growing inferno spread unstoppably outward in all directions, eating through one system after another. Warnings began to trip in the cockpit as critical wiring went up in smoke.
“I’ve got a spoiler light,” said First Officer Davidge. Another warning flicked on. “Gear unsafe light!” he said.
In response to air traffic control, Captain Allan said, again without a callsign, “Okay, heading one three zero, and uh, understand you want us up to 3,000 feet?”
Staring at the growing array of warning lights, First Officer Davidge said, “Okay, I thought I blew a tire.”
By now the hydraulic lines had been leaking for long enough to seriously degrade the pressure in the hydraulic system. The controls started to become sluggish and unwieldy as they reverted to fully manual operation.
“Okay, one six zero,” Captain Allan said, responding to another ATC instruction meant for Saudia 738. “And we’re losing our hydraulics sir, we’re going to need to, uh, come back to Jeddah to land.”
Meanwhile, First Officer Davidge and Flight Engineer Fehr pulled out the hydraulic failure checklist.
“Autopilot, yaw damper’s off,” Davidge said, reading off the first items.
“Off,” Fehr confirmed.
“We’re losing hydraulics here,” Davidge said, probably to Allan.
“The air brake thing just broke!” Allan exclaimed.
“We’ve got a flap-slat light!” said Davidge.
Captain Allan told air traffic control that they were leveling off at 3,000 feet.
“Level off right now, right now, level off!” Fehr shouted.
But the controller still thought they were Saudia 738. “Yeah, I will give you further descent,” he said. “Descend… initially, right now, 3,000 feet.”
“Okay, leveling at 3,000 feet and, uh, if you could give us a heading back towards — ”
“We’re declaring an emergency!” Davidge interrupted.
“ — the runway, we’ll advise you of the problem. We’re declaring an emergency at this time. We believe we have, uh, blown tires sir, over,” Allan concluded.
But in response, the controller suggested runway 16, which was only appropriate for Saudia 738. Allan declined and asked for runway 34.
“Okay, your pump pressure’s okay, Vic?” Allan said to the Flight Engineer.
“All the pumps are going, I’m gonna…” Fehr started to say.
“Okay folks, we got an unlock light,” said Davidge.
As the fire expanded exponentially, it burst through the floor above the wheel wells and emerged into the cabin. The horror that befell the passengers — mostly peasants from rural Africa for whom the Hajj was their first time on a plane — can only be imagined. Sheer panic likely took hold as people scrambled through the aisles to escape the searing flames and choking smoke, only to discover that with 261 people packed into the narrow body plane, there was nowhere for them to go. Behind a blinding pall of smoke, passengers burned to death where they stood, jammed like sardines between the blazing seat rows.
At that moment the lead flight attendant burst into the cockpit. “[There’s] smoke in the back, real bad!” she exclaimed.
“Yeah, we’re going back, we’ve got blown tires and a hydraulic problem,” Allan said to her.
The flight attendant responded, but it is not known what she said.
“Yeah, just tell them we’ll be returning to Jeddah,” Allan replied. Turning back to the other pilots, he said, “Okay. Let’s get squared away and see what we’ve got here.”
By now the plane was turning to line up with runway 34C, but the controller still thought he was speaking to Saudia 738. He instructed the crew to intercept the approach heading, but there was no reply.
“Okay, what I’ve got is a slat light…” said Allan.
“You’ve lost all hydraulics,” said Fehr. “I’ve got aileron, rudder power off.”
Indeed, not only had the main hydraulic system failed, so had the standby hydraulic system, which powers the rudder in an emergency. First Officer Davidge was flying the plane in full manual reversion, using strength alone to move the DC-8’s massive control surfaces.
The controller now instructed Nigerian 2120 to climb to 5,000 feet, not realizing that this was the emergency aircraft he had been speaking to for the past several minutes. Again, the crew did not reply.
At that moment, First Officer Davidge exclaimed, “I’ve got no ailerons!”
“Okay, hang on, I’ve got it!” said Captain Allan. His aileron controls seemed to be working, but only barely.
Just seconds later, the cockpit voice recorder ceased recording as the fire burned through the cables connecting it to the cockpit microphones. But the plane continued to fly, with Captain Allan handling the controls and working the radio as Davidge and Fehr frantically tried to stay on top of the cascading list of mechanical failures.
Only now, after several minutes of confusion and another erroneous order to climb, did the flight crew and the controller finally reconcile the misunderstanding about the plane’s identity. “Roger, roger, I thought other traffic is Saudi 738,” the controller said, finally providing the correct heading to the runway.
“Okay sir, 34 left, we are turning left to zero eight zero now and maintaining two thousand, we have flight control problems,” Allan reported.
The flight data recorder now captured the plane veering left and right and up and down in an unstable dance as the pilots fought for control. Witnesses on the ground could see smoke streaming behind the plane, growing in intensity with every passing moment.
Twice the controller attempted to contact the crew, and twice there was no reply.
Then at 08:35, Allan said to ATC, “Nigeria 2120 declaring an emergency, we are on fire, we are returning to base immediately!”
On board the plane, conditions became nightmarish beyond all description. The fire burned such a large hole in the fuselage that objects began to fall from the plane, including passengers, all of them burned beyond recognition. A horrifying hail of singed life vests, blackened seat cushions, and charred bodies began to rain down on the streets of Jeddah. And still the DC-8 kept flying, visibly consumed in flames, pieces of burning debris ripping off like streamers in its wake. The flight data recorder ceased functioning, but still Captain Allan continued his desperate transmissions: “Require emergency vehicles immediately, we have a fire, we will be ground evacuating…”
At 08:37, Allan announced his intention to land, but after that there would be no reply. The plane continued to fly for another minute or so in a desperate descent toward runway 34L, her pilots struggling to land a crippled airplane filled with the dead and dying. No one knows what they said and did in those last, terrible moments. But at approximately 08:38 and 35 seconds, just 2.8 kilometers short of the runway, they ran out of time. Witnesses struggled to comprehend what they were seeing, and so accounts of the flight’s ultimate demise vary: some say the plane exploded in flight, others said it abruptly rolled over and dived into the ground, and yet another said that the plane broke in half in midair, its tail section spiraling in behind the burning fuselage. All that is known for sure is that the plane finally struck the ground in a steep descent while banked sharply to the right, slamming into the barren desert in an enormous fireball. Of the 261 passengers and crew, none would survive.
Within hours of the crash, an investigation was launched, led by the Presidency of Civil Aviation of the Kingdom of Saudi Arabia. But because the crash involved a Canadian aircraft and a Canadian crew, the involvement of Canada’s Transportation Safety Board (TSB) was so extensive that the Canadians appear to have effectively ghost-written the final report on the accident. As such, it provides an insightful level of detail into the precise events leading up to the disaster, even though it occurred in a country not known for its transparency.
As determined by the investigation team, the fire began when a tire failed during takeoff; it was subsequently drawn into the wheel well when the landing gear was retracted, where it eventually destroyed the aircraft. From forensic evidence and witness statements, it was clear that the conflagration all but consumed the airplane in flight, leading to progressive system failures which culminated in the pilots’ loss of control over the pitch of the airplane. Whether this eventual loss of control occurred because the fire ate through the elevator cables, because the weakened fuselage bent and broke the cables, or because the tail section simply fell off, could not be determined, and in fact it didn’t really matter. With such a large and destructive fire on board, a crash was inevitable regardless of the specific failure that finally brought down the plane.
Although there was some speculation that the confusion with air traffic control delayed the plane’s return to the airport, the evidence did not bear this out, and investigators ultimately concluded that flight 2120 would not have landed any sooner in any conceivable scenario. However, that did not mean that the plane was always doomed to crash. One of the central questions of the investigation hinged on the actions of the crew: specifically, why didn’t they reject the takeoff when they realized that a tire had failed?
When the First Officer first heard a sound and identified it as a blown tire, the speed of the airplane was about 70 knots — barely half their decision speed of 141 knots. They had plenty of time to decide to stop, but for some reason they didn’t.
It turned out that Nationair only trained its pilots to reject a takeoff for one of three scenarios: an engine failure, an engine fire, or a total electrical failure. It may have been expected that pilots would abort for other failures, but except for these three mandatory reject items, the decision to stop or continue rested solely with the captain. Captain Allan, however, had not received any training related to tire failures, nor did he likely believe that a blown tire was a serious problem. Industry wisdom held that it was better to take off with a blown tire than to try to stop, especially at high speed. But in this case the speed of the plane at the time of the failure was low enough that stopping would have been trivial, and several pilots told investigators that they would indeed have rejected the takeoff in Allan’s place. The TSB and its Saudi counterparts theorized that the cues Captain Allan received must not have been sufficiently clear for him to decide that rejecting the takeoff was desirable. For this reason, investigators concluded that his decision to continue was consistent with his training, effectively absolving him of blame. But in an addendum to the report, the American NTSB warned that this conclusion risked sending the wrong message to pilots: ideally, they argued, pilots should always reject the takeoff in the event of a blown tire at low speed, and the training should be changed to reflect this indisputable fact.
Even after flight 2120 lifted off, disaster could have been averted if the crew had left the landing gear down instead of retracting it. Some airlines at the time trained their crews not to retract the landing gear if damage to the tires was suspected, but Nationair was not one of them: the airline had provided no specific guidance for pilots in the event of a tire failure on takeoff, and many pilots interviewed for the investigation were broadly unaware of the risks of retracting damaged landing gear. Indeed, large segments of the industry seemed to be treating tire failures as a non-serious event which required no special training or procedures. Had they known that retracting the gear could damage the extension mechanism or start a fire, the pilots of flight 2120 might have acted very differently.
Unfortunately, once they retracted the gear, the crew had little recourse. The Douglas DC-8 was designed in the 1950s and its fire detection systems are extremely primitive; there are no smoke, fire, or heat detectors in the wheel wells, landing gear, or cabin, nor were there any means to fight the fire besides a few handheld fire extinguishers. Even if the flight attendants used them — and no one knows whether they did — they would have done nothing to stop the raging inferno that consumed the plane.
In any case, the actions of the pilots were only a small part of a much larger story leading up to the failure of the tire. Investigators established that the #1 tire failed because the #2 tire next to it was critically underinflated and was not carrying its share of the weight. Furthermore, various members of the Nationair support team were aware that the tire was underinflated, but the plane was dispatched anyway, in violation of regulations.
Once again, much seemed to hinge on a lack of awareness of the consequences of operating with underinflated tires. Most of the literature available to the maintenance staff emphasized underinflation’s negative impact on a tire’s service life, but did not clearly state that it could lead to the failure of the tire within days. Nor were any of the mechanics aware that a blown tire could be a flight safety problem.
Considering this lack of knowledge, it was not hard to see why the mechanics, having detected low pressure in the #2 and #4 tires on the 7th of July, may have believed that it would be a non-issue to operate on those tires for another three days until their scheduled replacement. They might even have viewed inflating them as a waste of time and resources.
Subsequently, the A-check log was altered to hide the low tire pressure readings that were recorded on the 7th. Although this is illegal, there was no evidence that the mechanics’ intent in doing so was malicious; rather, they probably thought the tire pressure would be checked as normal once the tires were replaced and simply updated the figures “proactively.” Certainly, nobody seemed to be under the impression that the tires had really been inflated, nor did anyone try to argue that they were when interviewed by investigators.
There was some evidence that Lead Mechanic J. P. Philippe was not entirely comfortable with the length of time his team was letting the underinflated tires continue in service. The very fact that he asked for the tires to be inflated before the accident flight, when he knew that the wheels would be replaced upon arriving in Sokoto later that day, suggested that he wanted to hedge his bets. Nevertheless, the problem must not have been serious enough in his mind to prompt him to ask until 20 minutes before departure, and he subsequently boarded the plane himself without confirming that the tires had actually been inflated, clearly suggesting that he didn’t see a serious safety risk. Furthermore, even though he was seated in the jump seat behind the pilots throughout the flight, Philippe never mentioned the underinflated tires or raised the possibility that they were the cause of the blowout, adding to the evidence that he was unaware of the consequences of underinflation.
All of this inadequate knowledge collided with the team’s imperative to fulfil Nationair’s contractual obligations. Lead Mechanic Philippe had promised that the Hajj deployment would be smooth, and he had been overtly seeking a promotion, two factors which might have led him to take greater risks to keep the plane on schedule. Similarly, Project Manager Aldo Tetamenti was explicitly directed by his boss, the Vice President of Planning, to ensure that they adhered to the contract. He was not a mechanic, nor did he have any specific knowledge in this area, and if the actual mechanics did not appreciate the risks of flying with underinflated tires, then he certainly didn’t either. Nevertheless, he twice overruled Philippe’s judgment on maintenance matters, first when he told the team not to replace the wheels and tires in Accra on July 10th, and again when he decided not to search for Nitrogen before the departure of the accident flight.
Tetamenti’s urgent fax on the 10th showed that he placed fulfilment of the contract above any maintenance concerns, but it also showed that he didn’t understand what the contract actually said. According to the terms, Nationair was not liable for any delays or canceled flights, unless it was deemed at fault for the delays, in which case it would have to pay back the lessee’s initial deposit for any canceled services. The 33-hour grounding earlier that week for the failed weather radar was not Nationair’s fault, and as such they had not incurred any penalties up to that point, nor would they incur any for conducting routine maintenance. Had the mechanics gone ahead and replaced the tires, Nationair would not have owed their lessees anything, even if Nigeria Airways put its passengers on other planes.
The unclear delineation of authority and muddled decision-making within the Nationair team were symptomatic of a more fundamental lack of organization. There were multiple overlapping chains of command; for example, the Project Manager and the Operations Officer had the same job description but reported to different departments. Furthermore, adherence to procedures was sporadic at best. In addition to the items already mentioned, mechanics were not performing tire pressure tests during pre-flight checks, even though this was required. Mechanics believed they could detect visually if a tire was low, but testing showed that this was false. Nor did they properly fill out the paperwork for the pre-flight checks. And the flight engineers were responsible for signing off on the airworthiness of the plane before each flight, in lieu of a dedicated maintenance engineer, but in practice they did not oversee the maintenance work and could not know whether it was done properly, rendering their role meaningless.
Investigators also noted that the team was making inefficient use of the plane’s downtime, contributing to their difficulties. Even though the plane averaged nine-hour stopovers in Jeddah and two-hour stopovers in Africa, nearly all the maintenance work was performed in Africa under massive time pressure. It turned out that upon arriving in Jeddah, the team had been informed by local contacts that getting to the ramp at the Hajj terminal required going through customs, where they could be turned away if they were not part of the crew of a departing flight. On top of this, Lead Mechanic Philippe was keen to show his superiors that his connections in Africa were key to the success of the deployment. These two factors led to the otherwise ill-advised decision to jam the maintenance into brief African stopovers, a practice which directly contributed to the team’s failure to replace the tires before the accident occurred.
The poor organization of Nationair’s Hajj deployment led investigators to examine whether these systemic issues existed elsewhere in the company. However, the results of this line of inquiry proved inconclusive. By and large, Canadian investigators felt that Nationair was making a genuine effort to comply with regulations and did not have an especially high number of incidents or violations. Nevertheless, the company’s safety program was extremely primitive, and there were some problems with its management style. The airline’s founder Robert Obadia apparently ran the company like a dictatorship, and he fostered a management culture which had been described as “vindictive.” Pilots complained that they would receive financial penalties if found at fault in an incident, encouraging crews to cover up their mistakes. Furthermore, during a financial crunch in 1989, the airline abruptly laid off hundreds of employees and cut pay by 12% across the board, leading to lingering resentment. Many employees felt that this culture pressured them to prioritize the “company mission” over safety concerns, even if this goal was never explicitly stated by management. And many Nationair pilots also told investigators that they had “deviated from accepted norms in order to achieve on-time performance,” but few were willing to give specifics.
The company’s labor relations were also rather fraught. On a personal level, it was said that Captain Allan and First Officer Davidge were barely on speaking terms. More broadly, an ongoing dispute had led to bad blood between the pilots and the flight attendants. A number of pilots resented the fact that they were forced to downgrade from the 747 to the DC-8 after an expected contract in the Middle East failed to materialize. And in one especially brutal incident, flight attendants walked off a Nationair plane in Florida after being asked to complete an 18-hour duty day; Nationair responded by firing the flight attendants and then suing them to recoup the cost of canceling the flight.
After the accident, Nationair began taking steps to improve safety under the watchful eye of Transport Canada. However, the reforms would ultimately prove meaningless. The crash and subsequent media coverage irreversibly harmed Nationair’s reputation, and it quickly fell into severe financial difficulty. As the money dried up, labor disputes escalated, and in the fall of 1991 Nationair staged a lockout of its unionized flight attendants, bringing in strikebreakers to keep operations going while they bled the unions dry. The lockout finally ended in early 1993, but the flight attendants didn’t get their jobs back for long, because just one week later the airline filed for bankruptcy over tens of millions of dollars in unpaid fees owed to the Canadian government.
Meanwhile, court proceedings revealed that Nationair founder and president Robert Obadia had used his position to give himself low-interest loans and special dividends, even as the company owed employees and creditors vast sums of money. The discovery led Obadia to be charged with eight counts of fraud, but he never went to prison and his current whereabouts are unknown.
Following its bankruptcy in 1993, Nationair ceased to exist, and the relatives of the victims were suddenly left with no way to receive financial compensation. In fact, none of the 261 families ever received anything from Nationair — not even an apology, let alone any money. Most of the families never got their loved ones’ bodies either: only nine of the fourteen crewmembers were identified, and no attempt was made to identify the passengers, who mostly lacked the sort of records which would normally be used for this purpose.
The crash did lead to better safety throughout the aviation industry. As a direct result of the accident, passenger jets today have smoke detectors and fire extinguishers in the wheel wells, and tire safety is taken much more seriously, with airlines and repair shops required to teach mechanics and pilots about the consequences of tire failures and how to react should they occur. Today it is unlikely that a crew would continue a takeoff after experiencing a blown tire at 70 knots, and even if they do, few would dare to retract the landing gear afterward.
For most people, however, the crash of flight 2120 evokes our worst fears about flying. There is no real doubt that this was a hard way to die. Pathologists would later estimate that one third of the passengers burned to death while the plane was still in the air, trapped inside a narrow metal tube as the inferno overtook them. What nightmares did they witness in their final moments, as fire ripped through living bodies stacked like cordwood in the smoke-filled aisles? What acts of fruitless heroism did the flight attendants attempt, as their passengers burned alive before them? Perhaps it is well that we will never know.
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