 The Air Accidents Investigation Branch (AAIB) has released its final report into the incident, which happened on January 17, 2008.
The British Airways 777 was carrying 136 passengers from Beijing when it lost power as it came in to land at the west London airport.
It was forced to touch down within the airfield boundary, but 330 metres short of the runway.
The build-up of ice in the fuel system had restricted the flow of fuel to its engines.
The AAIB said: "Certification requirements, with which the aircraft and engine fuel system had to comply, did not take account of this phenomenon as the risk was unrecognised at that time."
The report added that research in the 1950s had identified the problem of ice formation in fuel systems from dissolved or trapped water, but did not identify the scenario of accumulated ice release and subsequent restriction to fuel flow.
The jet slid 372 metres on its undercarriage before coming to rest.
The left main landing gear (MLG) collapsed and the right MLG separated from the plane. All the passengers were safely evacuated, with one passenger breaking a leg.
All told, 34 passengers and 12 cabin crew suffered minor injuries, mainly to the back and neck.
The report said the cabin crew, led by Captain Peter Burkill, had become aware of a possible engine thrust problem just 43 seconds from touchdown.
Losing speed, the crew tried to increase engine thrust but there was no response from the engines. With a touchdown short of the runway inevitable, a Mayday call was put out three seconds before.
The AAIB made a total of 18 safety recommendations including some that address plane "crashworthiness", the ability of an aircraft to withstand an accident.
A British Airways spokesman said: "We welcome this final report. The crew of BA38 did a fantastic job in extremely difficult circumstances."
BA added that although there were no specific safety recommendations for the airline, it had worked with the relevant authorities and manufacturers "to ensure that the highest safety levels are maintained". |
