British Airways Flight 5390
|Date||10 June 1990|
|Summary||Explosive decompression due to faulty maintenance|
|Site||Didcot, Oxfordshire, England|
|Aircraft type||BAC 1–11 528FL|
|Aircraft name||County of South Glamorgan|
|Flight origin||Birmingham Airport|
British Airways Flight 5390 was a scheduled passenger flight operated by British Airways between Birmingham Airport in England and Málaga, Spain. On 10 June 1990 an improperly-installed panel of the windscreen failed, blowing the plane's captain, Tim Lancaster, halfway out of the aircraft, with his body firmly pressed against the window frame. The first officer managed to perform an emergency landing in Southampton with no loss of life.
The aircraft, County of South Glamorgan, captained by 42-year-old Tim Lancaster, who had logged 11,050 flight hours, and co-piloted by 39-year-old Alastair Atchison, who had logged 7,500 flight hours, was a BAC One-Eleven Series 528FL registered as G-BJRT. It took off at 07:20 local time, with 81 passengers, four cabin crew and two flight crew. Co-pilot Atchison handled a routine take-off, and relinquished control to Lancaster as the plane established itself in its climb. Both pilots subsequently released their shoulder harnesses, while Lancaster loosened his lap belt as well.
At 07:33, the cabin crew had begun to prepare for meal service. The plane had climbed to 17,300 feet over Didcot, Oxfordshire. Suddenly, there was a loud bang, and the fuselage quickly filled with condensation. The left windscreen, on the captain's side of the cockpit, had separated from the forward fuselage. Lancaster was jerked out of his seat by the rushing air and forced head first out of the cockpit, his knees snagging onto the flight controls. This left him with his whole upper torso out of the aircraft, and only his legs inside. The door to the flight deck was blown out onto the radio and navigation console, blocking the throttle control which caused the plane to continue gaining speed as they descended, while papers and other debris in the passenger cabin began blowing towards the cockpit. On the flight deck at the time, flight attendant Nigel Ogden quickly latched his hands onto the captain's belt. Susan Price and another flight attendant began to reassure passengers, secure loose objects, and take up emergency positions. Meanwhile, Lancaster was being battered and frozen in the 345 mph wind, and was losing consciousness due to the thin air.
Atchison began an emergency descent, re-engaged the temporarily disabled autopilot, and broadcast a distress call. Due to rushing air on the flight deck, he was unable to hear the response from air traffic control. The difficulty in establishing two-way communication led to a delay in British Airways being informed of the emergency and consequently delayed the implementation of the British Airways Emergency Procedure Information Centre plan.
Ogden, still latched onto Lancaster, had begun to suffer from frostbite, bruising and exhaustion. He was relieved by the remaining two flight attendants. By this time Lancaster had already shifted an additional six to eight inches out the window. From the flight deck, the flight and cabin crew were able to view his head and torso through the left direct vision window. Lancaster's face was continuously hitting the direct vision window; when cabin crew saw this and noticed that Lancaster's eyes were opened but not blinking despite the force against the window, they assumed that Lancaster was dead. Atchison ordered the cabin crew to not release Lancaster's body despite the assumption of his death because he knew that releasing the body might cause it to fly into the left engine and cause an engine fire or failure which would cause further problems for Atchison in an already highly stressful environment.
Atchison eventually received clearance from air traffic control to land at Southampton, while the flight attendants managed in extreme conditions to free Lancaster's ankles from the flight controls and hold on to him for the remainder of the flight. By 07:55 the aircraft had landed safely on Runway 02 at Southampton. Passengers immediately disembarked from the front and rear stairs, and emergency crews retrieved Lancaster.
Lancaster was taken to Southampton General Hospital, where he was found to be suffering from frostbite, bruising and shock, and fractures to his right arm, left thumb and right wrist. Flight attendant Nigel Ogden suffered a dislocated shoulder, frostbitten face and some frostbite damage to his left eye. Everyone else left the aircraft unhurt.
Less than five months after the accident Lancaster was working again. He later retired from British Airways when he reached the company's mandatory retirement age of 55 at the time. As of 2005, Lancaster was flying for easyJet.
Accident investigators found that a replacement windscreen had been installed 27 hours before the flight, and that the procedure had been approved by the shift maintenance manager. However, 84 of the 90 windscreen retention bolts were 0.026 inches (0.66 mm) too small in diameter, while the remaining six were 0.1 inches (2.5 mm) too short. The investigation revealed that the previous windscreen had been fitted with incorrect bolts, which had been replaced on a "like for like" basis by the shift maintenance manager without reference to the maintenance documentation. The air pressure difference between the cabin and the outside during the flight proved to be too much, leading to the failure of the windscreen. The incident also brought to attention a design flaw in the aircraft of the windscreen being secured from the outside of the aircraft, putting a greater pressure on the bolts than if they were secured from the inside.
Investigators found the British Airways Birmingham Airport shift maintenance manager responsible for installing the incorrect bolts during the windscreen replacement and for failing to follow official British Airways policies. They also found fault with British Airways' policies, which should have required testing or verification by another individual for this critical task. Finally, investigators found the local Birmingham Airport management responsible for not directly monitoring the shift maintenance manager's working practices.
Investigators made eight safety recommendations in the final accident report:
- Review their quality assurance system and encourage engineers to provide feedback.
- Review the need to introduce job descriptions and terms of reference for engineering grades Shift Maintenance Manager and above.
- Review their product sample procedure to achieve independent assessment of standards and to conduct an in-depth audit into the work practices at Birmingham Airport.
Civil Aviation Authority
- Examine the continued viability of self-certification with regards to safety critical tasks on aircraft.
- Review the purpose and scope of the FOI 7 Supervisory Visit.
- Consider the need for the periodic training and testing of engineers.
- Recognise the need for the use of corrective glasses, if prescribed, in association with aircraft engineering tasks.
- Ensure that, prior to the issue of an air traffic control rating, a candidate shall undergo an approved course including training in both the theoretical and practical handling of emergency situations.
This incident was featured on the Discovery Channel Canada programme Mayday (National Geographic Air Crash Investigation in other parts of the world), called "Blow Out", which was retitled Ripped From The Cockpit: BA Flight of Terror when broadcast on Channel 5 in the UK.
First officer Alastair Stuart Atchison and cabin crew member Susan Gibbins were awarded the Queen's Commendation for Valuable Service in the Air.
Atchison was awarded a 1992 Polaris Award for his ability and heroism.
Use of flight number
- Civil Aviation Authority
- Lists of accidents and incidents on commercial airliners
- John Stapp: USAF Colonel whose experiments proved survival in high speed ejections was possible.
- List of accidents and incidents involving military aircraft: In an incident similar to BA Flight 5390 on 9 July 1991, the bombardier of an A-6 Intruder was partially ejected from his aircraft while in flight due to an ejection seat malfunction. Despite being subjected to windblast and severe cold, as well as mechanical injury of being slammed repeatedly against the aircraft, Lt. Keith Gallagher survived and returned to flight status following the successful carrier landing of the aircraft by pilot Lt. Mark Baden.
- "This is your captain screaming (interview with Nigel Ogden)". The Sydney Morning Herald. 5 February 2005. Retrieved 21 April 2008.
- Official AAIB report, p.38
- The London Gazette: . 30 December 1991. Retrieved 18 May 2010.
- "British Airways (BA) #5390 Flight Tracker". FlightAware. Retrieved 30 January 2013.
- Air Accident Investigation Branch
- Accident description at the Aviation Safety Network
- Rule, Sheila. "4 Miles Over Britain Pilot Is Sucked Out; Crew Holds On Tight." The New York Times. 11 June 1990.