Narrative:
British Airways flight 5390 to Malaga, Spain, took off from Birmingham International Airport at 07:20 hrs.
The co-pilot had been the handling pilot during the take-off and, once established in the climb, the captain was handling the aircraft in accordance with the operator's normal operating procedures. At this stage both pilots had released their shoulder harness, using the release bar on the buckle, and the captain had loosened his lap-strap.
At 07:33 hrs as the cabin staff prepared to serve a meal and drinks, and, as the aircraft was climbing through about 17,300 feet pressure altitude, there was a loud bang and the fuselage filled with condensation mist. It was at once apparent to the cabin crew that an explosive decompression had occurred. The captain had been partially sucked out of his windscreen aperture and the flight deck door had been blown onto the flight deck where it lay across the radio and navigation console. The No 3 steward, who had been working on the cabin side of the door, rushed onto the flight deck and grasped the captain round his waist to hold onto him. The purser meanwhile removed the debris of the door and stowed it in the forward toilet. The other two cabin staff instructed the passengers to fasten their seat belts, reassured them and took up their emergency positions.
The co-pilot immediately attempted to control the aircraft and, once he had regained control, initiated a rapid descent to FL110. He re-engaged the autopilot which had become disconnected by displacement of the control column during the captain's partial egress and made a distress call on the frequency in use but he was unable to hear its acknowledgment due to the noise of rushing air on the flight deck. There was some delay in establishing two-way communications and consequently the Bristol Sector Controller was not immediately aware of the nature of the emergency. Meanwhile the purser re-entered the flight deck and, having hooked his arm through the seat belts of the fourth crew member jump seat which was located behind the left-hand pilot's seat, was able to assist the No 3 steward in the restraint of the captain. The two men tied to pull the captain back within the aircraft and, although they could see his head and torso through the left Direct Vision window, the effect of the slipstream frustrated their efforts. The No 2 steward entered the flight deck and he was able to relieve the No 3 steward whose arms were losing their strength as they suffered from frostbite and bruising from the windscreen frame. The No 2 steward grasped the captain's right leg, which was stuck between the cockpit coaming and the control column whilst his left leg was wedged against his seat cushion. The steward then strapped himself into the left jump seat and was able to grasp both of the captain's legs but not before he had moved a further 6 to 8 inches out of the window frame. He held him by the ankles until after the aircraft had landed.
Meanwhile, the aircraft had descended to FL100 and slowed to about 150 knots(kt). The co-pilot had requested radar vectors to the nearest airport and had been turned towards Southampton Airport and eventually transferred to their approach frequency. Having verified that there was sufficient runway length available for a landing, the co-pilot manoeuvred the aircraft onto a visual final approach to runway 02 and completed a successful landing and stop on the runway at 07:55 hrs. The engines were shut down but the Auxiliary Power Unit, which the co-pilot had started up during the descent, was left running to provide electrical power to certain aircraft systems. As soon as the aircraft came to a halt, passengers were disembarked from the front and rear airstairs while the airport and local fire services recovered the captain back into the aircraft from his position half out of the windscreen frame, where he had remained throughout the descent and landing. He was taken to Southampton General Hospital suffering from bone fractures in his right arm and wrist, a broken left thumb, bruising, frostbite and shock. The other crew members and passengers were medically examined but apart from one steward who had cuts and bruising to his arm there were no other injuries.
An investigation showed that the left windscreen, which had been replaced prior to the flight, was blown out under effects of the cabin pressure when it overcame the retention of the securing bolts, 84 of which, out of a total of 90, were of smaller than specified diameter.
The following factors contributed to the loss of the windscreen:
- A safety critical task, not identified as a 'Vital Point', was undertaken by one individual who also carried total responsibility for the quality achieved and the installation was not tested until the aircraft was airborne on a passenger carrying flight.
- The Shift Maintenance Manager's potential to achieve quality in the windscreen fitting process was eroded by his inadequate care, poor trade practices, failure to adhere to company standards and use of unsuitable equipment, which were judged symptomatic of a longer term failure by him to observe the promulgated procedures.
- The British Airways local management, Product Samples and Quality Audits had not detected the existence of inadequate standards employed by the Shift Maintenance Manager because they did not monitor directly the working practices of Shift Maintenance Managers.
Forced landing on runway
accident date: 10-06-1990
type: BAC One-Eleven 528FL
registration: G-BJRT
| Status: | Accident investigation report completed and information captured |
| Date: | Sunday 10 June 1990 |
| Time: | 07:33 |
| Type: |  BAC One-Eleven 528FL |
| Operator: | British Airways |
| Registration: | G-BJRT |
| MSN: | 234 |
| First flight: | 1971 |
| Total airframe hrs: | 37724 |
| Engines: | 2 Rolls-Royce Spey 512-14DW |
| Crew: | Fatalities: 0 / Occupants: 6 |
| Passengers: | Fatalities: 0 / Occupants: 81 |
| Total: | Fatalities: 0 / Occupants: 87 |
| Aircraft damage: | Substantial |
| Aircraft fate: | Repaired |
| Location: | over Didcot ( United Kingdom)
|
| Phase: | En route (ENR) |
| Nature: | Int'l Non Scheduled Passenger |
| Departure airport: | Birmingham International Airport (BHX/EGBB), United Kingdom |
| Málaga Airport (AGP/LEMG), Spain | |
| Flightnumber: | BA5390 |
British Airways flight 5390 to Malaga, Spain, took off from Birmingham International Airport at 07:20 hrs.
The co-pilot had been the handling pilot during the take-off and, once established in the climb, the captain was handling the aircraft in accordance with the operator's normal operating procedures. At this stage both pilots had released their shoulder harness, using the release bar on the buckle, and the captain had loosened his lap-strap.
At 07:33 hrs as the cabin staff prepared to serve a meal and drinks, and, as the aircraft was climbing through about 17,300 feet pressure altitude, there was a loud bang and the fuselage filled with condensation mist. It was at once apparent to the cabin crew that an explosive decompression had occurred. The captain had been partially sucked out of his windscreen aperture and the flight deck door had been blown onto the flight deck where it lay across the radio and navigation console. The No 3 steward, who had been working on the cabin side of the door, rushed onto the flight deck and grasped the captain round his waist to hold onto him. The purser meanwhile removed the debris of the door and stowed it in the forward toilet. The other two cabin staff instructed the passengers to fasten their seat belts, reassured them and took up their emergency positions.
The co-pilot immediately attempted to control the aircraft and, once he had regained control, initiated a rapid descent to FL110. He re-engaged the autopilot which had become disconnected by displacement of the control column during the captain's partial egress and made a distress call on the frequency in use but he was unable to hear its acknowledgment due to the noise of rushing air on the flight deck. There was some delay in establishing two-way communications and consequently the Bristol Sector Controller was not immediately aware of the nature of the emergency. Meanwhile the purser re-entered the flight deck and, having hooked his arm through the seat belts of the fourth crew member jump seat which was located behind the left-hand pilot's seat, was able to assist the No 3 steward in the restraint of the captain. The two men tied to pull the captain back within the aircraft and, although they could see his head and torso through the left Direct Vision window, the effect of the slipstream frustrated their efforts. The No 2 steward entered the flight deck and he was able to relieve the No 3 steward whose arms were losing their strength as they suffered from frostbite and bruising from the windscreen frame. The No 2 steward grasped the captain's right leg, which was stuck between the cockpit coaming and the control column whilst his left leg was wedged against his seat cushion. The steward then strapped himself into the left jump seat and was able to grasp both of the captain's legs but not before he had moved a further 6 to 8 inches out of the window frame. He held him by the ankles until after the aircraft had landed.
Meanwhile, the aircraft had descended to FL100 and slowed to about 150 knots(kt). The co-pilot had requested radar vectors to the nearest airport and had been turned towards Southampton Airport and eventually transferred to their approach frequency. Having verified that there was sufficient runway length available for a landing, the co-pilot manoeuvred the aircraft onto a visual final approach to runway 02 and completed a successful landing and stop on the runway at 07:55 hrs. The engines were shut down but the Auxiliary Power Unit, which the co-pilot had started up during the descent, was left running to provide electrical power to certain aircraft systems. As soon as the aircraft came to a halt, passengers were disembarked from the front and rear airstairs while the airport and local fire services recovered the captain back into the aircraft from his position half out of the windscreen frame, where he had remained throughout the descent and landing. He was taken to Southampton General Hospital suffering from bone fractures in his right arm and wrist, a broken left thumb, bruising, frostbite and shock. The other crew members and passengers were medically examined but apart from one steward who had cuts and bruising to his arm there were no other injuries.
An investigation showed that the left windscreen, which had been replaced prior to the flight, was blown out under effects of the cabin pressure when it overcame the retention of the securing bolts, 84 of which, out of a total of 90, were of smaller than specified diameter.
Probable Cause:
The following factors contributed to the loss of the windscreen:
- A safety critical task, not identified as a 'Vital Point', was undertaken by one individual who also carried total responsibility for the quality achieved and the installation was not tested until the aircraft was airborne on a passenger carrying flight.
- The Shift Maintenance Manager's potential to achieve quality in the windscreen fitting process was eroded by his inadequate care, poor trade practices, failure to adhere to company standards and use of unsuitable equipment, which were judged symptomatic of a longer term failure by him to observe the promulgated procedures.
- The British Airways local management, Product Samples and Quality Audits had not detected the existence of inadequate standards employed by the Shift Maintenance Manager because they did not monitor directly the working practices of Shift Maintenance Managers.
Accident investigation:
 |
|
Classification:
Wrong installation of parts Forced landing on runway
Follow-up / safety actions
AAIB issued 8 Safety Recommendations
Show all...
Show all...
Photos
accident date: 10-06-1990
type: BAC One-Eleven 528FL
registration: G-BJRT
Map
This map shows the airport of departure and the intended destination of the flight. The line between the airports does not display the exact flight path.
Distance from Birmingham International Airport to Málaga Airport as the crow flies is 1755 km (1097 miles).
Accident location: Global; accuracy within tens or hundreds of kilometers.
Distance from Birmingham International Airport to Málaga Airport as the crow flies is 1755 km (1097 miles).
Accident location: Global; accuracy within tens or hundreds of kilometers.
This information is not presented as the Flight Safety Foundation or the Aviation Safety Network’s opinion as to the cause of the accident. It is preliminary and is based on the facts as they are known at this time.
The Aviation Safety Network is an exclusive service provided by:
