Underinflated Tires and an Undetected Fire Brought Down Nigeria Airways Flight 2120
Episode 19 of Take to the Sky: the Air Disaster Podcast features the story of Nigerian Airways Flight 2120, a charter flight operated by Nationair that crashed on July 11, 1991, while attempting to make an emergency landing near Jeddah, Saudia Arabia. The investigation uncovered a culture of profit over safety within the airline, which led to a sequence of events culminating in a fatal inflight fire shortly after takeoff, killing all 261 people onboard. Flight 2120’s legacy has made flying safer today with the addition of onboard fire detection and prevention systems, which if they had been in place at the time, would have prevented the disaster.
Nigerian Airways Flight 2120 Experiences Issues During Takeoff Roll
It is July, and the Hajj is in progress, which is when Muslims gather in the holy city of Mecca in Saudi Arabia for their annual pilgrimage. The five-day journey is a once-in-a-lifetime obligation for all Muslims who are physically and financially able to undertake it. The King Abdulaziz International Airport in Jeddah, Saudia Arabia is suited perfectly for this religious pilgrimage as it even has a terminal dedicated solely to Hajj pilgrims.
And on July 11, 1991, Nigerian Airways Flight 2120, a charter flight operated by Nationair, which is a Canadian airline, is taking a group of 247 pilgrims home to Sokoto, Nigeria. These passengers would have likely been from under-resourced, remote villages, and most of them would never have been on a plane before. So, this was a very meaningful, important journey to the passengers.
Flight 2120 is also a DC-8, which at the time, is considered to be a sturdy and reliable aircraft. The plane is also carrying 14 crew, including the flight crew. Captain William Allan is a former Canadian Air Force pilot and has over 10,00 flight hours including 1,000 hours in the DC-8. First Officer Kent Davidge has logged 8,000 flight hours, of which 550 hours are in the DC-8, and is the pilot flying on this flight. Flight engineer Victor Fehr has 7,500 flight hours, of which 1,000 hours are in the DC-8. Also onboard are two other Nationair employees: lead mechanic Jean-Paul Phillippe and the project manager, Aldo Tettamanti.
Though it is just about 8:30 in the morning, the day is already a steamy 86 degrees Fahrenheit. The airport has a vast airfield, and Flight 2120 must taxi 3 miles to get into takeoff position. With the intense heat, a long taxi on a paved runway can make people onboard a little uncomfortable.
As the plane starts down the runway, almost immediately, things start to go wrong. Right after calling for maximum thrust, the crew hears a flapping or oscillating sound. Flight Engineer Fehr asks, “What is that?” First Officer Davidge suggests they may have a flat tire. The crew can hear the strange flapping sound again, and this time, Captain Allan wants to make sure that the First Officer has not inadvertently touched the break rudders with his feet, which if he had, it may have caused the sound. But Davidge confirms he is not touching the break rudders.
Despite the sound they hear, none of the instruments show any sign of trouble. And then right before lift-off and just as they pass V-1, the First Officer says the wheels seem to be shimmying. The captain calls out “rotate”, and as they get lift off, the crew next retracts the landing gear.
Multiple System Alarms Trigger Inside Nigeria Airways Flight 2120 Cockpit
Just one-minute and fifteen seconds later, as they being to climb toward 1,500 feet, things start to escalate quickly inside the cockpit. The Flight Engineer calls out that they have four low pressure indicators, and then he tells the Captain and First Officer the plane is losing pressure. To ensure the plane is pressurizing properly, Captain Allan tells First Officer Davidge to level off. And to the passengers in the cabin at this moment, nothing would necessarily seem wrong, although many probably realized the plane had, for some reason, leveled off.
The Captain radios air traffic control (or ATC) to inform them Flight 2120 is leveling off at their current altitude (at around 2,000 feet) because they are experiencing a small pressurization issue. Over the next three minutes, several alarms go off and lights come on, which include a spoiler light (which was odd because they had not deployed the spoilers – they are used to reduce lift upon landing), a gear unsafe light (which comes on if the gear is not fully up or down), AND a loss of hydraulics (which means control of the plane may now be compromised).
Meanwhile, as things are starting to get more urgent, this next set of events does not help: the controller back at ATC has his hands full, and at the same time as Flight 2120, another plane also reports an issue of improper pressurization. But the controller thinks he is talking to one aircraft, not two. So, he tells Flight 2120 they can descend to 3,000 feet. But Flight 2120 is currently below that altitude at 2,500 feet. Confused, the Captain reconfirms that ATC wants them to climb to 3,000 feet, and the controller confirms yes. This confusion lasts another three minutes with ATC assuming they are speaking to another flight and not to Flight 2120.
Next, the plane starts to experience a loss of hydraulics, and the crew must resort to taking manual control of the plane. It becomes very difficult to use the control column and both the Captain and First Officer would need to do this since the control column is now very hard to turn and steer. At this point, Captain Allan radios ATC and tells them the plane needs to return immediately to Jeddah and land. The journey back to the airport means Flight 2120 would have to make a wide left turn that would momentarily take them away from the airport but then return them over the city to line up with the runway.
Smoke Fills Cabin of Nigerian Airways Flight 2120
Meanwhile, unbeknownst to the pilots, at the same time, thick smoke appears in the cabin and is visible to passengers. This is just less than 3 minutes after takeoff. And this smoke is very visible and very thick, with the heaviest smoke toward the middle and back of the plane. Fearful passengers run toward the front of the aircraft to get away from the ever-thickening smoke. This is a terrifying reality because fire can literally destroy an airplane in minutes.
The flight crew levels the plane off at 3,000 feet and tells ATC they are experiencing a hydraulic issue and that they are declaring an emergency. The Captain and flight crew still know nothing about the smoke in the cabin until a flight attendant rushes into the cockpit and tells the flight crew there is a lot of smoke in the cabin. The Captain informs her to let passengers know the plane is returning to Jeddah. Now, the crew must deal with the threat of fire in addition to all these other system failures and alarms. And though clearly these things are all connected, they don’t know how.
Nigerian Airways 2120 Pilots Fight for Flight Control Amid Inflight Fire
Things are rapidly spinning out of control on Flight 2120. Jeddah is 11 miles away and First Officer Davidge can no longer steer the plane because the ailerons have failed, too. Both Captain Allan and First Officer Davidge struggle with the control columns.
Finally, ATC realizes they have been speaking with not one plane but two and clears Flight 2120 to land anywhere.
In the cabin, the billowing smoke turns to fire. At this point, it would be almost impossible for any passenger to breathe, and the situation is now fatal. Chaos becomes pandemonium as passengers try desperately to escape the fire, which has by now burned through the floor. The fuselage burns quickly, first the floor and then consuming seats and rows one by one. Debris starts to break away from the fuselage, and then bodies fall from the plane to the ground thousands of feet below.
Desperate to get on the ground, the crew lines up the plane with the runway, but in the exact moment they put down the landing gear, the plane is suddenly engulfed in flames. It crashes down nose first into the earth at about a 70-degree angle, just short of the runway, exploding on impact. The plane is all but obliterated, and everyone on board dies: all 247 passengers and 14 crew members. At the time, it is the worst crash for a Canadian airline and the worst ever crash involving a DC-8.
The day following the crash, on July 12, investigators from the Transportation Safety Board (TSB) of Canada arrive in Jeddah and join the official crash investigation led by the Saudi Arabian Ministry of Defense and Aviation. While the Saudis officially lead the investigation and publish the final accident report, they don’t have the extensive crash investigation experience that the TSB does, who is there to assist Saudi officials in determining the cause of the crash.
Nigeria Airways Flight 2120 Crash Leaves Debris, Bodies Strewn Along 13-Mile Path
When the TSB investigators arrive, the first thing they see is the massive debris field, and they are instantly shocked by the destruction. It is widespread, and the breakup of the plane was exceptionally severe when it hit the ground and exploded. Hardly any recognizable pieces of the plane still exist. And the passengers whose bodies were still on the plane show extensive damage and horrific injuries, including charring and severe impact injuries. It’s something investigators will never forget.
The debris is spread in a V-shape that measures 1,300 feet long and 650 feet wide with fire markings all over the area. In addition to this crash area, debris and bodies have been strewn about over a 13-mile area. In fact, one of the passenger’s bodies was found 13 miles from the airport, making it crucial for investigators to search this entire area to ensure they locate all debris and additional bodies that fell out of the plane. Bodies recovered from the main wreckage site show burns consistent with the flash fire that took place post-impact. One-third of the bodies showed burns sustained prior to impact. The crew in the cockpit suffered very little to no burns. The pattern tells them that the plane hit the ground in a severe downward motion, rupturing all the fuel tanks. It came in at a low-nose, right bank attitude, just after an in-flight break up.
TSB Investigators Identify Source of Inflight Fire on Nigeria Airways Flight 2120
Investigators eventually find major pieces of the plane and start to map out the spread of the debris in an effort to piece together what happened at the moment of impact. All they know for sure is, there was a fire onboard. One of their first major tasks is to identify the source of that fire and determine how it progressed throughout the plane. When sorting through the extremely damaged plane wreckage, they must determine, for each piece, if that piece was burnt in flight or upon impact. And there is a way to tell: the parts that burned in air look almost like molten rock while those parts that burnt in the impact explosion have a smoother burn surface. When investigators have evaluated all the major pieces of the plane, they find that the front of the plane shows the least in-air fire damage while the center fuselage shows the greatest in-flight fire damage. Now investigators know the fire likely began in the plane’s midsection, and as the plane flew in air, the flames trailed from the middle toward the back of the plane and started burning there as well. But something else interests them: they find a section of the wall from the interior center part of the fuselage that shows a clear burn-through pattern. This is likely where the fire first came into the cabin from below.
This discovery leads investigators to check out the wheels and landing gear as this equipment is near the source of the fire. Investigators compare the inner wall damage of the fuselage with a section of one of the plane’s left wheels that also shows significant fire damage. This particular wheel shows damage consistent with having been scraped against the very hot runway asphalt. If this indeed happened, this scraping action would have generated a lot of heat around the tire.
Nigerian Airways Flight 2120 Maintenance Records Were Forged
Soon after this discovery, an investigator finds a piece of paper in the plane’s debris field that heats up the investigation: it is a maintenance checklist log for the tires on Flight 2120, and it shows that the tires were inflated to a normal pressure per square inch (or PSI) prior to takeoff on July 11th. But something isn’t right about the checklist: investigators notice it has writing in two different colors of ink, indicating that the original numbers for the tire pressure may have been changed. Because altering any maintenance record in aviation is against the law, investigators send the document to the Royal Canadian Mounted Police (or RCMP) for further analysis.
When the RCMP analysis is completed, they confirm that the maintenance log has indeed been tampered with. Specifically, they discovered the original readings for the tire pressure have been written over. The log originally showed that the tire pressure on Flight 2120 was 20-30 PSI below levels safe to operate the plane. The numbers had been written over with falsified numbers to make it look like the tires had been safely inflated. Following this line of investigation, and after interviewing members of the maintenance team, investigators uncover some disturbing evidence as they investigate the airline’s operations.
Nigeria Airways Flight 2120 Took Off with Underinflated Tires
Four days prior to the crash, mechanics wanted to change the tires because the tires had low tread and low pressure. But, the project manager, Aldo Tettamanti, who was also on Flight 2120 when it crashed, told the mechanics not to change the tires because that work would cause a delay in takeoff. So, the tires were never changed. The project manager was clearly afraid that the airline would lose the contract if the flight was late. So, the mechanic changed the tire pressure numbers on the maintenance log. There is no evidence that the plane’s tire pressure had been checked with an actual tire gauge since July 7th.
With this new information come to light, investigators realize that when the plane arrived in Jeddah three days later, the tires were obviously underinflated. At 5 AM on the day of the crash, the crew arrives for its pre-flight checks. The project manager, Aldo Tettamanti, finally decides to get the tires topped off. But the mechanic tells Tettamanti that he needs nitrogen to fill the tires. Nitrogen is used on airplane tires because it expands less in heat and is less flammable. The mechanic also observed that the rear inboard tire of the left main landing gear seemed to be especially underinflated.
A ramp supervisor drove the mechanic to a support facility to find nitrogen. But the only available nitrogen was at another airline and getting it would create a delay. Tettamanti tells the mechanic to just forget about the nitrogen, that the plane needs to take off as scheduled.
The big issue here is that the Tettamanti, as a project manager, is neither an engineer nor a pilot, so when he makes that decision, he literally is making the flight unsafe. This is not a decision he should have made. The captain should have been told, and all evidence points toward Captain Allan not knowing anything about the underinflated tires.
Investigators also look at tire tracks on the runway from the time when the plane took off, and they observe that the left main landing gear had been leaving black marks that continued down the runway for some distance. They find bits of blown tire on this same left side, concluding that Flight 2120 blew its two left tires from the main landing gear, which are coincidentally, in the plane’s midsection.
The answer to why the tires blew lies in what happened right before take-off. As mentioned at the beginning of the story, Flight 2120 taxied for 11 minutes in the desert heat, which meant the tires were literally heating up right on the tarmac. Also, fully inflated tires ensure that the weight of the plane is evenly distributed across all tires. But when a plane has underinflated tires, as Flight 2120 did on the left side, the weight is not distributed equally over the remaining wheels. One of the tires was 28 PSI below the safe level. And as the tires continue to heat up, the nylon begins to melt and pull apart. And then, eventually, the tire will blow.
Blown Tires Leads to Fatal Inflight Fire Onboard Nigerian Airways Flight 2120
The blown tires then set off a sequence of events that sealed the plane’s fate. First, Flight Engineer Fehr heard a sound and asked, “What’s that?” Then the First Officer responded, “We gotta flat tire, you think?” An oscillating sound can be heard on the cockpit voice recorder (CVR). Around this time, rubber marks on the runway show that the number 1 tire from the left main landing gear started to break up. And then the second tire’s wheel rim begins to scrape the runway, also depositing rubber marks on the runway. The captain then calls out V-1, which is when the First Officer says the wheels feel like they are shimmying. It is at this time that tire number 2’s wheel rim was being ground away into the asphalt of the runway. This friction creates sparks and fire. Shortly thereafter, the plane becomes airborne, and the captain retracts the landing gear, which brings the fiery wheels up into the well in the midsection of the plane. They unknowingly brought the fire up into the wheel wells and into the bottom of the fuselage.
Witnesses on the ground report to investigators that the takeoff seemed normal except that sparks and flames were seen in the left main landing gear section. And, then they watched as the fiery landing gear was retracted into the plane. These accounts confirm what investigators think happened.
Things happen quickly in a downward spiral of terror from there for everyone onboard. The fire starts to burn through the bottom of the fuselage, then up through the fuel tanks, into the electrical systems, and finally through the cabin floor. The fire was so bad that it completely burned through the cabin floor right above the wheel wells, causing the cabin furnishings to sag into the wheel wells. This caused bodies to star falling from the sky. The fuel from the fuel tanks obviously intensified the fire, until shortly before impact, the structural integrity of the plane was completely lost, and it started to break apart.
Investigators Find Probable Cause of Crash of Nigeria Airways Flight 2120
The Saudis release the final cause of the crash of Flight 2120: a lack of fire prevention in the wheel wells and a decision to fly with underinflated tires ultimately caused a fire. This fire developed within the left main wheel wells and subsequently caused loss of pressurization, hydraulic failure, structural damage, and loss of aircraft control. Because of this crash, they also find that the DC-8 is unfit to fly.
A key issue here is that the DC-8 did not have any fire or smoke sensors or detectors in this area that would have told the crew about the fire. The Saudis recommended that all transport aircraft be equipped with overheat and fire detectors, wheel well fire protection, brake temperature sensors, tire pressure sensors, and corresponding indicators in the cockpit.
They also found during the investigation little evidence of crew resource management or the use of emergency checklists. Their other recommendations included training of flight crews on tire performance and vulnerability to ensure safe operation and the formal inclusion of crew resource management in initial and recurring training. In the report, the Saudis cited that cockpit coordination seemed to be lacking, with the Captain and First Officer having different backgrounds. The captain had a military background and the First Officer had risen through small aircraft commercial piloting where he got to make decisions as opposed to a superior. The Captain was described as having a command-and-control style in the cockpit. The First Officer was reportedly uncomfortable with the captain’s style.
Lastly, they also recommended better monitoring of maintenance operations and training maintenance personnel n adequate tire servicing and tire vulnerability.
NTSB Finds Flight 2120 Pilots Had Greater Culpability than Report Assigned
The NTSB did not agree with everything in the Saudis report. On May 27, 1993, they wrote a letter to the Saudi Arabian Ministry of Defense and Aviation and said that the issue of flight crew decision-making and airmanship should have been given greater attention.
The NTSB said that the report should have clearly stated that the crew was aware of a problem during the takeoff roll while at a speed and with sufficient runway remaining to reject take off successfully. In their report, the Saudis said that the cues available to the crew were insufficiently demanding to make the captain believe a rejected takeoff was essential. They attributed this to conditioning factors including the captain’s training regarding takeoff decision speed and lack of adequate knowledge of the tire conditions or the consequences of operating an underinflated tire. The NTSB fired back that they believe this type of analysis sends the wrong message to crews and said the captain should have rejected takeoff just based on the fact that there was an abnormality present (remember: possible tire failure at low speed before V-1). The NTSB went on to further say that the Saudis should have focused instead on what the crew WAS trained on regarding damaged or underinflated tires and continuation of flight. The Saudis had reported that the captain’s training on the DC-8 did not include rejecting for tire or wheel failures, nor was there any such requirement.
And if the crew did not choose to reject the takeoff, the NTSB feels they should have made better decisions in air. Specifically, the NTSB stated that even though the exact origin of the vibration (or that oscillating sound) was not known to the crew, it would have been prudent and advisable under those circumstances to leave the landing gear extended for an immediate re-landing at Jeddah. They strongly believe if that had happened, the flight would have been survivable.
The NTSB recommended the following changes to the Saudi report:
- The crew had enough information to reject the takeoff.
- The captain did not react to available cues and continued takeoff.
- The crew retracted the landing gear, which brought burning tires into proximity with hydraulic and electrical systems.
- While retracting the landing gear was consistent with company policy, it was not an optimum action considering the possibility of tire failure during takeoff.
Beyond this difference in opinion among the investigative community, Flight 2120 has a critical legacy: all modern-day commercial airplanes have smoke and fire sensors in the wheel wells. And all flight and maintenance crews are trained on the importance of inflating tires and what happens when you do not.
Crash of Nigerian Airways Leads to Demise of Nationair
The crash also brings criticism to the way that Nationair conducted its operations. The airline’s culture of productivity over safety certainly contributed to this crash. An example of this culture is when the project manager made key, fatal decisions because of his concern over Nationair losing contracts if it were late.
The crash of Nigeria Airways Flight 2120, combined with Nationair's poor reputation for on-time service and mechanical problems, led to serious problems with the airline’s public image and reliability among tour operators. These difficulties were compounded when Nationair locked out its unionized flight attendants and proceeded to replace them with strikebreakers in November 1991. The lock-out lasted 15 months, and by the time it ended in early 1993, Nationair found itself in severe financial trouble. At the time, Nationair owed the Canadian government millions of dollars in unpaid landing fees. Creditors began seizing aircraft and demanded cash up-front for services. Subsequently, the company was declared bankrupt in May 1993, owing $75 million Canadian dollars. In 1997, Robert Obadia, owner of Nationair and its parent company Nolisair, pled guilty to eight counts of fraud in relation to the company's activities.
Family of Flight Attendant Who Died on Flight 2120 Unhappy with Treatment by Airline
Little has been written about who was onboard and the aftermath related to the victims.
A 2011 article from CTV news highlighted one of the victim’s families. Lina Colacci’s sister Dolores was a flight attendant on Flight 2120. Lina said, when it happened, it was all over CNN for a week, but a lot of people (in Canada) never heard about the crash. This seems to support what I found in my research for this story – very little has been written about the crash.
Lina said that Dolores had kept a journal and had written how she was scared that the safety of Nationair was lacking. The journal entries describe staff implementing makeshift repairs, such as plugging up holes in the bathroom with rags.
Lina added that Dolores was getting ready to quit because of the fear of something happening. This was mere weeks before the crash.
And the treatment of the family after the crash by Nationair was completely insensitive. After an early-morning phone call from a Nationair representative informing the Colacci family that there had been an accident, it took another week before they learned that Dolores' body could not be recovered. Nationair told them that the bodies were cremated in the air because of the explosion. However, the airline did offer an alternative as it recognized the need for closure: it volunteered to put some sand in a coffin and ship it back under the pretext that it contained Dolores' remains.
The Colacci family declined. The family states they never received anything from Nationair, not even an apology. Despite the contentiousness that existed between the crew and the airline, the crew themselves at Nationair were very close. A group of Toronto-based Nationair flight attendants pooled funds to create a memorial plaque, inscribed with the names of the victims. The memorial, complete with a cherry tree planted to commemorate their colleagues who died in Jeddah, was given a permanent home at the head office of the Greater Toronto Airports Authority. The friends and families of the victims said they did it so no one would ever forget them.
And THAT is the story of Nigeria Airways Flight 2120, operated by Nationair.