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Accident
Last updated: 28 July 2016
Status:Schlussbericht
Datum:Sonntag 10 Juni 1990
Zeit:07:33 UTC
Flugzeugtyp:Silhouette image of generic BA11 model; specific model in this crash may look slightly different
BAC One-Eleven 528FL
Fluggesellschaft:British Airways
Kennzeichen: G-BJRT
Werknummer: 234
Baujahr: 1977
Betriebsstunden:37724
Triebwerk: 2 Rolls-Royce Spey 512-14DW
Besatzung:Todesopfer: 0 / Insassen: 6
Fluggäste:Todesopfer: 0 / Insassen: 81
Gesamt:Todesopfer: 0 / Insassen: 87
Sachschaden: schwer beschädigt
Konsequenzen: Repaired
Unfallort:über dem Didcot (   Großbritannien)
Flugphase: Während des Fluges (ENR)
Betriebsart:Internationaler außerplanmäßiger Passagierflug
Flug von:Birmingham International Airport (BHX/EGBB), Großbritannien
Flug nach:Málaga Airport (AGP/LEMG), Spanien
Flugnummer:5390
Unfallbericht:
The accident happened when the aircraft was climbing through 17,300 feet on departure from Birmingham. 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 commander was sucked halfway out of the windscreen aperture and was restrained by cabin crew whilst the co-pilot flew the aircraft to a safe landing at Southampton Airport.

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.

Informationsquelle:

Official accident investigation report
investigating agency: Air Accidents Investigation Branch (AAIB) - United Kingdom
report status: Final
report number: AAIB AAR 1/92
report released:1 February 1992
duration of investigation: 1 year and 8 months
download report: Report on the accident to BAC One-Eleven, G-BJRT, over Didcot, Oxfordshire on 10 June 1990 (AAIB AAR 1/92)

Sicherheitsempfehlungen

AAIB issued 8 Safety Recommendations

Show all AD's and Safety Recommendations

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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).

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