British Airways Flight 5390
|Date||10 June 1990|
|Summary||Explosive decompression due to faulty maintenance|
|Site||Didcot, Oxfordshire, England|
|Injuries (non-fatal)||2 (minor)|
|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 Airport in Spain. On 10 June 1990 an improperly installed panel of the windscreen failed, at 17,400 feet (5,300 m), blowing the plane's captain, Tim Lancaster, halfway out of the aircraft. With Lancaster's body firmly pressed against the window frame for over twenty minutes, the first officer managed to perform an emergency landing at Southampton Airport 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 17,400 feet (5,300 m) 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 propelled out of his seat by the rushing air from the rapid decompression 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, causing the aircraft to continue gaining speed as it descended, while papers and other debris in the passenger cabin began blowing towards the cockpit. He hung out the window for a moment or more, when at the time, flight attendant Nigel Ogden saw the situation in the cockpit, and quickly rushed to latch his hands onto the captain's belt. Susan Price and another flight attendant began to reassure passengers, secure loose objects, and organise emergency positions. Meanwhile, Lancaster was being battered and frozen in the 345 mph wind, and was losing consciousness due to the thin air, with the outside air temperature around -17 C / 1.4 F, not including the chill from the incredible wind.
Atchison began a very rapid emergency descent to reach an altitude with oxygen because the plane was not equipped to provide it for all persons on board. Then he 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 a delay in 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 could see his head and torso through the left direct vision window. Lancaster's face was continuously hitting that 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 not to release Lancaster's body despite the assumption of death because he knew that a released body might fly into the left engine, in turn causing an engine fire or failure.
Eventually Atchison was able to hear the clearance from air traffic control to land at Southampton, while the flight attendants managed in the 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.
There were no major injuries during the flight. Much to everyone's surprise, Lancaster was found to be alive, and 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. In 2005 Lancaster was reported as 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, in order to save time as the plane was due to take off soon and there was a tight schedule. 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.
The windscreen was recovered in a field outside Didcot, Oxfordshire by officers from Thames Valley Police. With earlier officers having not searched for or collected the bolts from the site, PC Tony Nash returned to the site and located a number of the windscreen bolts that assisted in determining the cause of the incident.
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.
First Officer Alastair Stuart Atchison and cabin crew members Susan Gibbins and Nigel Ogden were awarded the Queen's Commendation for Valuable Service in the Air; Ogden's name was erroneously missed from the published supplement.
Atchison was awarded a 1992 Polaris Award for his ability and heroism.
Use of flight number
- Civil Aviation Authority (United Kingdom)
- List of accidents and incidents involving commercial aircraft
- John Stapp: USAF Colonel whose experiments proved survival in high speed ejections was possible.
- List of accidents and incidents involving military aircraft (1990–99): 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.
- "GINFO Database". Civil Aviation Authority.
- "SPECIFICATIONS". bac1-11jet.co.uk. Retrieved 31 October 2015.
- "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.