from smoke inhalation. Seventy-eight passengers and four crew escaped, with 15 people sustaining serious injuries. One passenger, a man rescued 33 minutes after the start of the fire, was found unconscious in the aisle, but died in the hospital six days later from injuries to his lungs and the resulting pneumonia. Causes The Air Accidents Investigation Branch (AAIB) report lists a cause for the accident and a separate cause for the fatalities, as well as four contributing factors. Accident The subsequent investigation into the incident said that the No. 9 combustor can on the port engine ruptured, and a section of the can was ejected forcibly into an underwing fuel tank access panel. That panel was fractured, allowing fuel to spill onto hot combustion gases from the engine. The resulting fire developed catastrophically, primarily due to the orientation of the aircraft and the fire to the wind, "even though the wind was light." Fatalities The AAIB concluded, "the major cause of the fatalities was rapid incapacitation due to the inhalation of the dense toxic/irritant smoke atmosphere within the cabin, aggravated by evacuation delays caused by a forward right door malfunction and restricted access to the exits." Contributing factors The AAIB listed the following as major contributory factors: The vulnerability of the wing tank access panels to impact The lack of any effective provision for fighting major fires inside the aircraft cabin The vulnerability of the aircraft hull to external fire The extremely toxic nature of the emissions from the burning interior materials. Previous engine repair Records showed the engine in question, a Pratt & Whitney JT8D-15, had experienced previous cracks to the No. 9 combustor can that had been repaired in 1983 by fusion welding. The repair did not include solution heat treatment, which was a required procedure for this type of repair. The AAIB evaluated conflicting evidence on the effect of solution heat treatment and "considered that it would not have had a significant effect on the fatigue life of the can." The circumferential edges of the severed forward section of the No. 9 can coincided with some of the cracks that had been welded during that repair. Some of the fracture was in areas where no cracking had been seen at the time of the repair, and the fracture edges were severely damaged during the failure and the ensuing fire. Therefore, the AAIB could not conclude whether the