British Airways Flight 5390
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| Summary | |
|---|---|
| Date | June 10, 1990 |
| Type | Explosive decompression |
| Site | Didcot, Oxfordshire |
| Fatalities | 0 |
| Injuries | 2 |
| Aircraft | |
| Aircraft type | BAC One-Eleven |
| Operator | British Airways |
| Tail number | G-BJRT |
| Passengers | 81 |
| Crew | 6 |
| Survivors | 87 (all) |
British Airways Flight 5390 was a British Airways flight between Birmingham International Airport in Birmingham, England and Málaga, Spain. On June 10, 1990 the airplane suffered an explosive decompression when an improperly installed pane of the windshield blew out; the flight crew managed to perform an emergency landing in Southampton with no loss of life.
Contents |
[edit] The incident
The aircraft, commanded by Tim Lancaster and co-piloted by Alistair Atchison, was a BAC One-Eleven Series 528FL with the registration code G-BJRT. It took off at 7:20 AM, local time, with 81 passengers, 4 cabin crew, and 2 flight crew on board. Co-pilot Atchison handled a routine liftoff, and relinquished control to the commander as the plane established itself in its climb. Both pilots subsequently released their shoulder harnesses, while Lancaster loosened his lap belt as well.
At 7:33 AM, the cabin crew had begun to prepare for meal service. The plane had climbed to 17,300 feet, and was moving over Didcot, Oxfordshire. Suddenly, passengers heard a loud bang, and the fuselage quickly filled with condensation. The left windshield, located on the commander's side of the cockpit, had suffered a catastrophic failure. Lancaster was jerked out of his seat by the rushing air and blown head first out of the cockpit; however, his knees had snagged onto the flight controls. The door to the flight deck was blown out onto the radio and navigation console, 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 commander's belt. Susan Price and another male flight attendant began to reassure passengers, secure loose objects, and take up emergency positions.
It was immediately apparent that the aircraft had suffered an explosive decompression, so the copilot began an emergency descent, re-engaged the temporarily disabled autopilot, and broadcast a distress call. Due to the rushing air on the flight deck, Atchison was unable to hear the response from air traffic control. The difficulty in establishing two-way communication indirectly 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. However, by this time, Lancaster had already shifted an additional 6 to 8 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.
The co-pilot eventually received clearance from air traffic control to land in Southampton, while the flight attendants managed to free and hold onto Lancaster's ankles for the remainder of the flight. By 7:55 AM, the aircraft had landed safely on Runway 02 in Southampton Airport. Passengers immediately disembarked from the front and rear stairs, and emergency crews retrieved Lancaster.
[edit] Injuries
Despite his serious injuries, Tim Lancaster survived. He was taken to Southampton General Hospital, where he suffered from frostbite, bruising, shock, and fractures to his right arm, left thumb, and right wrist. In addition, one flight attendant received minor cuts and bruises to his arm. Everyone else left the airplane unhurt.
[edit] The investigation
British accident investigators found that a replacement windshield 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 windshield retention bolts were 0.026 inches too small in diameter, while the remaining 6 bolts were 0.1 inches too short. The difference between the cabin and outside air pressure during flight proved to be too much, leading to the failure of the windshield.
Investigators blamed the British Airways Birmingham Airport Shift Maintenance Manager for installing the incorrect bolts during the windshield replacement and for failing to obey 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 blamed the local Birmingham Airport management for not directly monitoring the Shift Maintenance Manager's working practices.
[edit] Safety recommendations
Investigators noted eight safety recommendations in the final accident report:
[edit] British Airways
- 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 conduct and to conduct an in-depth audit into the work practices at Birmingham Airport.
[edit] 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.
- Recognize 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.
