- hace 41 minutos
On 10 June 1990, a cockpit window on British Airways Flight 5390 blows out, partially ejecting and injuring the captain through the hole. A flight attendant clings onto his legs as the first officer completes an emergency landing without any deaths. The captain is found to be still alive after being outside the cockpit for 21 minutes. The blowout was caused by a maintenance worker installing incorrectly sized bolts during maintenance work.
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00:23It must be one of the most amazing flying stories of all time, one that is still hard to believe.
00:28An airliner full of passengers out of control at 17,000 feet, and the pilot is stuck outside the plane.
00:39In the cockpit, three frightened flight attendants are clinging to his legs.
00:44If he slips from their grasp, the captain's body could be sucked into the engine and bring down the plane.
00:51At the controls, a young co-pilot is battling to get the plane to the nearest airport.
01:03The lives of 87 passengers and crew hang by a thread.
01:10A lot of people go through life thinking it will never happen to me.
01:14But you tend to go through life thinking it can.
01:17I said I thought I was going to die. I thought I was going to die.
01:21This bizarre accident tested the limits of human survival.
01:26And the investigation that followed not only exposed the mistakes behind it, but led to new ways of preventing them.
01:47The flight from Birmingham, England to Malaga, Spain, the 10th of June began like any other day.
01:54Old friends about to do a job they loved.
02:02Stewards Nigel Ogden and Simon Rogers, along with stewardess Sue Prince, had worked together on and off for years.
02:09They're an experienced, capable team that takes pride in its work.
02:14At Birmingham, all the cabin crew and all the pilots, they all knew each other, were all on first name
02:21terms.
02:22Simon was a good friend of mine anyway, because we, you know, just go out for a beer or a
02:27curry or whatever like that.
02:28Everybody was friendly to everybody else.
02:31The one new member of the group was Alistair Atchison, an experienced co-pilot he'd just driven down from Manchester
02:38that morning.
02:45Morning, Alistair. Come on in.
02:48Tim Lancaster is captain. He's been a commercial pilot for 21 years.
02:54Well, we've got to get started, eh?
02:58Chief Steward John Heward arrives to give the crew their final briefing.
03:03Morning, everyone.
03:05Morning.
03:06Is that the first officer?
03:08Yeah, just down from Manchester.
03:10I see a new face.
03:13OK, OK, Malaga.
03:15Right, I'm looking forward to this.
03:17Right, Nigel, you can sit up with me up front and talk rugby.
03:21Sue, where would you like?
03:23Over the wing.
03:24OK, so, Simon, you're at the rear.
03:27All right, now, just a few safety questions.
03:30Nigel.
03:32Before take-off, the co-pilot performs a walk-around, checking the outside of the aircraft for anything wrong.
03:40In the cockpit, Captain Tim Lancaster reviews a log of the maintenance carried out on the plane the day before.
03:47Everything OK?
03:48Fine.
03:49She's just come out of maintenance by the look of it.
03:52Nothing much, though.
03:54Just changed the windscreen.
03:56Many of the passengers know the flight well and are looking forward to a relaxed trip to Spain.
04:06I was going to catch a plane from Birmingham to Malaga to meet my mum.
04:10My sister and I were joining her there for a week's holiday, a girl's week.
04:16I live in the south of Spain and two or three times a year I come back to see my
04:22grandchildren and also my mother.
04:25So everyone lives near Birmingham, so that's the route I normally take, Malaga, Birmingham.
04:35These unsuspecting passengers and crew were about to begin an adventure of a lifetime.
04:41Seemed to have made yourself comfortable.
04:43Too right.
04:49Ladies and gentlemen, this is your captain speaking.
04:51My name is Tim Lancaster.
04:53Welcome aboard this British Airways flight to Malaga.
04:57He seemed laid back and quite jovial, really.
05:02Well, it's a lovely day in Malaga.
05:03Blue skies, sunshine.
05:05Sit back and enjoy the flight.
05:06We still expect to get you there on time.
05:10Birmingham Tower.
05:11Speedbird 5390.
05:12We're ready to start and push.
05:14Speedbird 5390.
05:15Clear to start and push.
05:19Ladies and gentlemen, we are now going to take you through our safety procedures and equipment.
05:23As this information is for your benefit, we ask you to watch and listen carefully.
05:27Clear to start engines.
05:29Starting number two.
05:32Emergency exits are on both sides of the air.
05:34The stewardess shows you the emergency exit and all the emergency gear.
05:42And, of course, nobody's really watching.
05:45One chap was quite blasé.
05:47He was reading the times.
05:48And people weren't really bothering because we've all been on flights.
05:50And, you know, it's no big deal.
05:53The air can be topped up by using the mouthpiece.
05:55And there is a whistle for attracting attention.
06:0780 knots.
06:15The BAC-111 was known as the Jeep of the skies.
06:19A workhorse that was easy to maintain and had a good safety record.
06:31At 43 tons, this pressurized hull is carrying 81 passengers and six crew.
06:37And is now climbing to 23,000 feet.
06:42In just over two hours, they should be in Spain.
06:47Only a catastrophic accident could bring this plane out of the skies.
06:53Alistair?
06:54I can see my house from here.
06:59Two minutes into the climb, the pilots switch on the autopilot.
07:03Tim Lancaster takes off his shoulder straps and relaxes into the flight.
07:08And I went into the flight deck to ask Tim and Alistair what they would like to drink.
07:15You gentlemen, like a tea?
07:17Please, the usual.
07:18Milk, one sugar, please.
07:19And I said, your breakfast, Tom, it'll only be a few minutes.
07:22Now, almost 13 minutes after take-off, and at 17,300 feet,
07:27they're just 5,000 feet from their assigned altitude.
07:30But then, in a split second, everything changes.
07:42With a huge explosion, the captain's windscreen blows out into the sky.
07:47Almost immediately, a white fog forms.
07:52I saw that really intense, stomach-body-shaking thud.
08:04We were just diving, really.
08:06And then we started to judder like this.
08:09And I was a bit stunned.
08:10I thought, what?
08:12Oh, God, it's a bomb.
08:17Alistair, the co-pilot, is suddenly fighting for control in a 350-mile-an-hour wind.
08:23There's no time to think about the captain,
08:26who's been blasted out of the window by pressurized air escaping from the aircraft.
08:34The rushing wind pins Captain Lancaster to the roof of the cockpit.
08:43Inside, his legs have jammed the control column forward,
08:47disconnecting the autopilot and pushing the plane down into a dive.
08:56Alistair Acheson needs all his flying experience now.
08:59He's on his own.
09:06The captain's body is pinned to the outside of the jet as it hurtles down from 17,000 feet.
09:12The throttles are jammed forward, increasing the speed to nearly 400 miles an hour.
09:18Co-pilot Alistair Acheson has to take command.
09:21While he fights to bring the plane under control,
09:24steward Nigel Ogden can see his captain is being sucked out of the aircraft.
09:30And I looked in, the flight deck door was resting on the controls,
09:35and all I could see was Tim out the window.
09:41I jumped over, put one foot in the captain's footwell,
09:46and the other one was down the side of his seat.
09:49I just grabbed him before he went out completely.
09:53Nigel Ogden holds on to the captain for dear life.
09:58Outside, a 390 mile an hour blast of wind,
10:02at minus 17 degrees centigrade, smashes into Tim Lancaster's body.
10:09The tornado in the cockpit is giving Acheson major problems.
10:18Air traffic control can hear his cries for help,
10:21but the storm rushing through the cockpit drowns out their replies.
10:29The captain's feet are still pushing against the control column,
10:32and Alistair is struggling to get full control of the plane.
10:36He's now diving through some of the busiest air lanes in the world,
10:40with the added danger of a mid-air collision.
10:48From the cabin, lead steward John Heward sees the chaos in the cockpit,
10:52and does what he can to help.
10:56I looked up, and there was Nigel sort of hanging across the seat in the flight deck.
11:01In front of me, the flight deck door had fallen forwards
11:04and trapped itself between the actual door frame
11:08and the throttles of the aircraft.
11:09So I literally stamped on it twice,
11:13and it literally broke into three or four pieces.
11:17Behind, on the wall of the flight deck,
11:19there is a spare seat for anybody to observe the flight or whatever.
11:23And I thought, well, if I put my arm through the seat belt there,
11:26I can grab both of them,
11:28and at least we've got some sort of anchor point inside the aircraft.
11:35Alistair, who's never flown with this crew before,
11:38has to leave them to their own devices
11:40and focus on getting the plane to safety.
11:44He now has control of the throttles.
11:47John and Nigel have wrenched the captain's feet away from the control column.
11:52But instead of slowing down,
11:54Hatchison decides to continue the rapid descent.
11:58It will quickly take him out of the way of any other air traffic
12:01and take him to a lower altitude where oxygen equipment won't be needed.
12:06Staying too long at a high altitude risks oxygen starvation,
12:10and this older aircraft is not fully equipped with oxygen for all the passengers on board.
12:17The airspeed indicator goes into the red.
12:30In the cabin, the two other stewards, Sue Prince and Simon Rogers,
12:35are trying to prepare the passengers for what they hope will, at worst, be an emergency landing.
12:50They've dived to 11,000 feet in just two and a half minutes.
12:53But as they level out and slow down to 170 miles per hour,
12:58the captain's body is no longer pinned to the roof
13:01and slides round to the side of the plane.
13:05Flight level 100.
13:060, 0, 5, right ahead in 195.
13:11Working his way from the back of the cabin,
13:14steward Simon Rogers now catches sight of the chaos in the cockpit for the first time.
13:23Now the aircraft had got to sort of flying fairly level,
13:26Simon came up from the back.
13:31Noice was beginning to get really sort of achy now with his arms,
13:34and I knew he wasn't going to let go unless he was sure that Tim wouldn't fly out of the
13:38window.
13:40We all had fear in our eyes.
13:42We were all worried sick because we thought, you know,
13:46either Tim's going to die or we're going to die, you know.
13:49That was going through my mind.
13:51But it was up to Alistair then, and it was up to us three,
13:55Simon and John and myself, to hold on to grim death.
14:01Mayday! Mayday! Mayday!
14:03All I remember is Tim's arms flailing out.
14:06His arms seemed about six foot long, and I'll never forget that.
14:10His eyes were wide open.
14:12I mean, his face was hitting the side of the side screen,
14:18but he didn't blink.
14:20And I thought to myself, and I said to John,
14:24I said, I think he's dead.
14:26I think he's dead.
14:29And I said, you and Si have to hold on.
14:33I can't hold on any more.
14:34I can't hold on any more. I've lost the feeling in my arms.
14:39Come on!
14:41Come on!
14:50And we decided to put Simon. I said to Simon, you sit in that jump seat and fasten yourself in.
15:01With Simon sitting in the seat, we'd freed Tim's legs from between the control column in the seat.
15:07So we hooked his feet over the back of the captain's seat, and then Simon literally put his hands on
15:11the top,
15:12just so he was holding his ankles down.
15:14Come on!
15:15Come on!
15:17Come on!
15:17Come on!
15:23Hey, look! What's going on?
15:25We're going to be all right, but I think the captain's dead.
15:29Well, I couldn't believe it, because he'd just told us what a lovely day it was.
15:32You know, blue skies, sunshine, relax and enjoy the flight.
15:36And the next minute, he's dead.
15:40Simon and Alistair now face one of their most difficult decisions.
15:44What to do with the lifeless body of the captain.
15:50No words are said, but for a moment, the thought passes between them
15:54that the best thing would simply be to let it go.
16:03No! Can you hold on to it, please?
16:06But Alistair's order isn't simply an act of compassion.
16:11Releasing the body at the position it was in, it would have gone close to the upper area of the
16:18wing.
16:18It could have damaged the leading edge of the wing.
16:20Had it gone over the wing, it could very well have gone into the engine.
16:23Quite a lot of damage could have been caused by the release of the body.
16:26So I think it was a very sensible decision to try and keep him where he was.
16:31Alistair has managed to get down to 11,000 feet.
16:35Without the captain to help, he's operating the plane's systems from memory
16:39and shepherding it around Heathrow.
16:43Some of the most congested airspace in the world.
16:47Seven minutes out of contact with the ground,
16:49he's able to hear the voice of air traffic control for the first time.
16:53...requesting radar assistance onto the nearest airfield, please.
16:57Speedbird 5390, roger.
16:59Can you accept landing at Southampton?
17:01Speedbird 5390, I am familiar with Gatwick.
17:05Would appreciate Gatwick.
17:06Alistair wants to land at Gatwick Airport, as he's flown there many times before.
17:12But Southampton is nearer, and even though he's never flown there before,
17:16he knows he has to get down fast.
17:18And I am on 150 knots, requesting radar assistance into Southampton.
17:23When you're going to an airport that you're not used to,
17:25you normally have charts, let-down plates,
17:29that kind of thing that you can read up on
17:32and learn something of the airport you're going to.
17:37But he knew nothing of Southampton, he hadn't been there,
17:40he had no charts because everything had gone out the window,
17:42there was no let-down plates to look at the approach, and so on.
17:48All the maps and charts blew out of the window with the captain,
17:51and only the air traffic controller can guide Acheson.
17:54He turns towards Southampton.
18:01Southampton, this is Speedbird 5390, do you read?
18:05Speedbird 5390, good morning.
18:09Identified on handover from London radar,
18:12six miles west of Southampton airfield.
18:14What is your passing level?
18:16Roger, sir, I am not familiar with Southampton.
18:19I request you shepherd me onto the runway.
18:21When he spoke, he was obviously stressed.
18:24It sounded as if he was under a fair bit of pressure.
18:28What is your number of persons on board?
18:30We have 84 passengers on board.
18:33And I think that will be all until we are on the ground.
18:36Roger, that's copied.
18:37I've been advised it's pressurisation failure.
18:39Is that the only problem?
18:41Negative.
18:45The captain is half out of the airplane, I understand.
18:50I believe he's dead.
18:54Roger, that is copied.
18:56My feeling was when he told me what was going on,
18:59it was one of disbelief, because it doesn't actually happen.
19:05You know, it's one of these things that you see in films,
19:07that happens in films, but it doesn't happen in real life.
19:11And it was sort of the hairs in the back of the neck go up
19:15and there's this feeling down the spine, the tingle down the spine,
19:19and you think, no, it's not for real, but it's got to be.
19:22Flight attendant holding on to him,
19:25but requesting emergency facility for the captain.
19:29I think he is dead.
19:33Affirm, what is your passing level?
19:35Leaving flight level 5,500 feet on turn 19.
19:41Roger, that's copied.
19:43I'll give you a little bit more space,
19:46then I'll turn you on to a heading of 180.
19:50Yeah, it's a full emergency.
19:52Rundle contacts the emergency services at the first opportunity.
19:55I don't know how many people are on board, but I'll let you know.
20:05Could you confirm that the level of runway at Southampton
20:09is acceptable for a 1.11?
20:12Yes, it is acceptable for a 1.11,
20:15and I'll give you the figures shortly.
20:17As long as we have at least 2,500 metres, I am happy.
20:23I'm afraid we don't have 2,500 metres.
20:27Neither do Bournemouth.
20:28We have a maximum of 18,000 metres.
20:38Acheson is concerned that the plane is above its maximum landing weight,
20:41being full of fuel for the journey to Malaga.
20:44And the BAC-111 can't dump fuel.
20:48If the runway isn't long enough, he faces more problems.
20:51Whether the aircraft could actually stop on the runway,
20:54or whether the tyres would burst,
20:55or whether he would go off the end of the runway.
20:58That's obviously what he was worried about when asking for 2,200 metres.
21:035-3-9-0.
21:05Thank you very much.
21:07We are...
21:10Three queens and...
21:13Flats.
21:1545.
21:15So we are set for approach, but make it please.
21:19Very gentle.
21:20Yes, I will indeed.
21:21You are number one traffic.
21:23If you think about it, all the airline pilot training is done with 2 pilots,
21:29both compos mentis in the cockpit.
21:31One flying the aeroplane, and the other one doing all the emergency drills.
21:35So what you actually had was the captain hanging out the window,
21:38at least one person hanging onto his legs,
21:41and Alistair flying the aeroplane with nobody else to talk to.
21:45Speedbird of 5390.
21:47Nine miles from touchdown, you're cleared to land.
21:49Wind indicates 020 degrees at 14 knots.
21:53Descent to height to 15000 feet.
21:55QFE is 1017.
21:58Roger, sir. Descending to 1500 feet.
22:02Talk me down the other way.
22:04I need all the help I can get.
22:07Roger, you'll be able to stop the aircraft on the runway,
22:10and evacuate the aircraft on the runway.
22:13He must have been about six or seven miles from touchdown.
22:16And obviously at that point I kept talking until he was happy he could see the runway.
22:21I was happy to continue looking out the window and land the aeroplane.
22:26At the point he said he was visual with the runway.
22:29I effectively stopped talking.
22:39You need not acknowledge unless requested it will be an uninterrupted talk down,
22:44but feel free to interrupt if you feel you need to.
22:475390, thank you very much.
22:50I have the runway in sight.
22:53Thank you, you are cleared to land.
22:55Do you wish me to continue with any further information?
22:58Negative.
23:0832 minutes after takeoff, with 81 terrified passengers,
23:12a nearly full fuel tank, and the captain blasted out of the window,
23:16Alistair Atchison attempts the most difficult landing of his career.
23:19.
23:24.
23:35Oh, my God.
23:56Oh, my God.
24:36I remember seeing the co-pilot, the man who really, if it wasn't for him, would have been on the
24:41other side by now, and is walking down the runway very slowly, shaking his head.
24:48And he got an ambulanceman walking with him, and his arm around the shoulders of the co-pilot.
24:55And the co-pilot was shaking his head as if... I remember that distinctly. I don't know why, but I
25:00do.
25:07I don't know why, but I do.
25:58I don't know why, but I do.
26:01Every 1,000 feet of altitude causes the temperature to drop by 2 degrees centigrade.
26:07So the temperature on the outside of the plane would have been around minus 17 degrees centigrade.
26:12The extreme wind chill also meant his body was losing heat very rapidly.
26:17He would have lapsed into semi-consciousness and then unconsciousness, and as the temperature, his core body temperature fell, he
26:24would have finally died as a result of the excessive cold in that environment.
26:31Despite the trauma that Captain Lancaster's body suffered, there was one final twist to his story.
26:46In the Oxfordshire countryside, John Heward and Nigel Ogden are visiting one of their crew members who shared their horrific
26:54experiences.
26:56Here he is.
26:58Hi, guys.
27:00John, how are you? Nice to see you.
27:02Nice to see you, Mike.
27:03Nice.
27:04Come in, come in.
27:05Hi.
27:05Like on SEP, when you go in and you've got to pretend...
27:07The captain of that fateful flight, Tim Lancaster, somehow survived his horrific ordeal.
27:13There were no fatalities on BA 5390.
27:16Yeah, that's it now. You can go on a three-day cruise across there.
27:21As his frozen, lifeless body was removed from the plane, nobody thought that Tim could have survived such punishment.
27:28But remarkably, he was slowly beginning to emerge from his horrific adventure.
27:33Tim, can you hear me?
27:35I regained some consciousness on the ground at Southampton because I remember big red and white things, which were obviously
27:40fire engines and ambulances, not people and not conversation.
27:44And then my next clear, lucid thoughts were in hospital in Southampton.
27:52Over the next few days, all the bits eventually arrived back in my sort of consciousness.
27:57And I put the jigsaw together and, you know, sort of played the whole story for myself.
28:03And, uh, understood what had happened.
28:12There was a big bang, a noise of all the air escaping.
28:16But I remember watching the windscreen move away from the aircraft, and then it had gone like a bullet.
28:21It disappeared into the distance.
28:24And I think there was an even bigger bang, or there was an even bigger bang.
28:30And I was very conscious of going upwards.
28:33And, uh, well, the whole thing became completely surreal then, as it would.
28:37And, uh, I was aware of being outside of the aeroplane, but, uh, that really didn't bother me a great
28:42deal.
28:42What I remember most clearly is the fact I couldn't breathe because I was facing into the airflow.
28:49And I turned it round, and actually turned my body round.
28:53I was sort of looking back along the top of the aircraft at that stage, and I could breathe it.
28:59And, yes, I remember that.
29:00I can remember seeing the tail of the aircraft.
29:02I can remember the engines going round.
29:04And, uh, and then I don't remember much more.
29:07Memory stopped at that point.
29:08I went down there last year, but they've changed the airpods.
29:12I'm glad I did hold on, because Tim was alive.
29:16I mean, he's a very strong man.
29:18He must have been.
29:19To survive that, I wouldn't have been able to survive it.
29:31That's all very dramatic.
29:33It is, isn't it?
29:34Tim Lancaster's survival was little short of miraculous.
29:37He'd been minutes away from death.
29:42It was Alistair Acheson's flying that saved his life.
29:45His quick thinking in getting the plane to the ground in only 22 minutes
29:49saved Lancaster from dying from the effects of exposure.
29:55And by pure chance, the physical trauma he suffered was limited.
29:59It included a bone fracture in his right arm and wrist,
30:03a broken left thumb, bruising, frostbite and shock.
30:08Remarkably, within five months, Tim Lancaster had made a full recovery
30:11and was flying again.
30:16Of course, the captain wasn't the only one to go through a horrific experience.
30:22Battling with the controls whilst a tornado raged through the cockpit
30:25was something no commercial pilot could be trained for.
30:32If it goes comfortable at all, just let me know.
30:38The few pilots who were able to understand the experience of Acheson and his crew
30:42include these young Royal Air Force trainees.
30:49They are being put through a simulation of an explosive decompression
30:53in this hypobarric chamber.
30:56It duplicates the effects of a window blowing out at 25,000 feet.
31:16The atmospheric pressure is initially set to 8,000 feet.
31:21This is the pressure inside the sealed cabin of most commercial aircraft.
31:25Anyone can survive this for many hours with no ill effects.
31:29Any higher than that, and the experience is very different.
31:34Students, listen in.
31:35Will all students please indicate with a clear thumbs up
31:37that they are ready for rapid decompression.
31:39Eight thumbs, rest your thumbs.
31:41Students, stand by for rapid decompression.
31:43In five, four, three, two, one, now.
31:51The mist in the hypobarric chamber is identical to the fog formed
31:55when the window blew out on BA5390.
31:59At the instant of rapid decompression,
32:01the air in the cabin can no longer hold onto its water vapour,
32:04which is then released into the atmosphere as fog.
32:13Chamber altitude is stable at 25,000 feet.
32:16High hold is enabled.
32:17Cross bend is on, and you're clear to commence hypoxia training.
32:19Good load on.
32:23Good look. That's hypoxia training on students 7 and 8.
32:26Once the fog clears,
32:28then the lack of oxygen at that height begins to tell.
32:31OK, let's pick out your misery.
32:33Start copying these sheets in the right-hand bar, gents.
32:37Without oxygen, at first we begin to see
32:40a reduction in their reaction speed,
32:43and we see personality changes,
32:46much like someone experiences when intoxicated with alcohol.
32:49So we see that some students become euphoric,
32:51some students become quite subdued,
32:54and some students begin to develop forgetfulness.
32:57Have a look at the ugliness of your colleagues' faces.
32:59See if they get any prettier whilst you're becoming hypoxic.
33:01We see increasingly impaired performance in our students.
33:05Thinking is slowed,
33:06and their reaction speed becomes increasingly slowed,
33:08until they begin to develop sort of lapses of concentration,
33:13falling into unconsciousness,
33:16and finally death if their oxygen supply is not re-established.
33:19The blood is no longer carrying as much oxygen as it was.
33:22This is all about you experiencing your personal symptoms
33:25and having others observe the symptoms in you.
33:34Flying alone, battling nearly 400-mile-an-hour winds,
33:38and defeating the possibility of oxygen deprivation,
33:42Alistair Atchison's achievement in saving flight 5390 was outstanding.
33:55Even as the crisis was unfolding,
33:58accident investigators were rushing to Southampton to find an explanation.
34:04On the ground at Southampton Airport,
34:06the search for clues begins.
34:09Initial investigation shows no distortion to the frame of the windscreen,
34:12so this rules out a problem with the structure.
34:15The fact that there are no shards of glass also discounts a bird strike.
34:25Stuart Culling, senior investigator with the air accident investigation branch,
34:29has little to go on.
34:33Windscreen was missing.
34:34There was a certain amount of blood around.
34:36There were some minor dents and scrapes on the fuselage,
34:40as you'd expect if the window had gone past.
34:42And really, that was about it,
34:44apart from a lot of paper scattered around inside.
34:48One of his first clues comes from the log recovered from the plane.
34:52He knows the plane had been serviced just the day before,
34:55and that a windscreen had been replaced.
34:58He immediately pays a visit
34:59to the British Airways maintenance hangar at Birmingham.
35:06I wanted to find out exactly what had happened
35:09to the aircraft before it took off,
35:11and I'd arranged that I should talk
35:13to the shift maintenance manager who fitted the window.
35:16There was a slight problem there
35:19because he'd been on night duty,
35:20and consequently he had finished his shift
35:23at roughly the same time
35:24as the windscreen came out of the aircraft,
35:26and he wasn't in a fit state to be interviewed.
35:29He needed to get some sleep.
35:34It's Stuart Culling.
35:35Good morning.
35:36Good to see you.
35:37I was expecting you.
35:38Yes, good.
35:39Thank you very much.
35:40Is this the hangar in question?
35:41This is the main hangar, yes.
35:43So in the meantime, I looked around the facility.
35:47I made sure that any paperwork
35:49and any records of the aircraft
35:51had been identified and taken away
35:53so they couldn't be accessed by anyone else,
35:56and waited until he came in.
36:04Hello, I'm from the AIIB.
36:06Yes, and this is my colleague.
36:08What I'd like to do today
36:09is just find out what went on
36:12during that shift pattern
36:14and how it went.
36:15Thank you very much.
36:20Did you notice anything about the window itself,
36:23any stress marks that were worrying you?
36:25My first conversation with the shift maintenance manager
36:28was relatively general,
36:30because at that stage,
36:31we had no evidence it was relevant.
36:34You didn't delegate it to somebody else
36:36and then check it?
36:36Stuart, there's a phone call for you.
36:38Just come in.
36:38Oh, right.
36:39Would you mind if I took this and...
36:41So I took the call
36:43and found that it was information
36:44about the windscreen
36:45which had been found in the didcut,
36:47and there were something like 30 bolts found with it,
36:50most of which were one size short in diameter,
36:53one size too small in diameter.
36:55It was a crucial error.
36:57On some planes,
36:58windscreens are fitted from the inside
37:00and use the internal pressure inside the cabin
37:03to keep them in place.
37:04But on the 111,
37:06the windscreen is bolted on from the outside.
37:09Any weakness in the bolts
37:10could mean that the pressure inside the plane
37:13would blow the windscreen out.
37:14It appears Culling has very quickly found the mistake
37:17and the guilty man.
37:20I've had some news,
37:21which I think is very relevant.
37:22I've heard from my colleagues
37:24who are working on the bolts.
37:26They tell me they're the wrong bolts.
37:28They're the wrong diameter.
37:30No, that's not possible.
37:32They're exactly the same bolts.
37:33And I took out of there.
37:35He's a professional man.
37:37He's very keen on doing things to his mind
37:41in the interests of the company.
37:43And he's suddenly told that he's put a windscreen in
37:45using bolts of the wrong size.
37:47And he's absolutely shocked.
37:50I can show you.
37:52I can show you the bolts I got out of there.
37:54One thing that came out was that he said,
37:56oh, the old bolts went into a waste bin
37:58in the hangar where he did the job
38:00and they may still be there.
38:01So he rushed across to the waste bin
38:03and found something like 80 discarded bolts.
38:06They've been here.
38:07This is where I put them.
38:08These are the bolts.
38:11And these are the ones you checked
38:13against the new ones?
38:14That's right.
38:14Yeah, I took them over there.
38:15From the carousel.
38:16There's really excellent evidence.
38:18Gold as far as I was concerned.
38:19Well, I'll take these away.
38:25By comparing the maintenance manual
38:27to what the engineer had told him,
38:30Kaling is quickly able to identify
38:31the first part of the sequence,
38:33what went wrong the previous night
38:35when the window of the BAC-111
38:37had been replaced.
38:40We went through the whole chain of events
38:42that had occurred
38:43and we found that
38:46there were something like
38:4713 different anomalies
38:51which led to the fitting of the bolts.
38:55And had any of these caused him to think,
38:58the sequence of events would not have continued
39:00and it wouldn't have been in action.
39:15The engineer had come early into his shift
39:17and at about 4 a.m. had gone to work
39:20removing the old windscreen from the plane.
39:23The hangar was full
39:24and the plane had been pushed
39:26against the hangar door
39:27which made the windscreen hard to reach.
39:30Stretched across the fuselage,
39:31he had problems controlling his screwdriver.
39:38The windscreen that he had taken out
39:40had itself been fitted
39:41with the wrong length bolts
39:42but they were still strong enough
39:44to hold the screen in
39:45and it survived without a hitch for 4 years.
39:48But he was a conscientious engineer
39:50and he decided that he would replace
39:53the old bolts with new ones
39:54when he installed the new screen.
40:00He chose not to go to the parts catalogue
40:02and look up the exact bolts he needed.
40:05Instead, he went straight to the parts store.
40:07Good morning.
40:08Good morning.
40:12There, he matched by eye new bolts
40:14with the ones he had taken out of the screen.
40:22His eye match was good
40:23and he found a few fresh bolts
40:25of exactly the same type in a drawer.
40:29What I'm after is I need 97 Ds.
40:32I'm just doing a windscreen on a 111 over there
40:33and I need some new bolts.
40:34Eight Ds on a 111?
40:36Well, no, these are seven.
40:37This is a seven.
40:38I've just taken it out.
40:39We haven't got any sevens anyway.
40:41Okay.
40:42The store manager knew which bolts
40:44the engineer should have been looking for
40:45but the engineer chose to ignore his advice.
40:50Instead, he drove to the other side of the airport
40:53to find a match for his bolts.
40:56It was now about 5.15 a.m.
40:59and in a dark corner of the hangar
41:01he continued to search for new bolts
41:03identical to the ones he'd taken out of the plane.
41:06But in the gloom, his luck finally ran out.
41:09He thought they matched, but they didn't.
41:11He picked bolts that were just over
41:13two hundredths of an inch too narrow for the job.
41:21Returning to the 111,
41:23he stretched over the plane
41:24and began fitting these new bolts.
41:27Working at an angle,
41:28he couldn't see that the new bolts didn't fit correctly.
41:41Signing off at 6 a.m.,
41:43the engineer had managed to get his work done in time.
41:46The plane was now ready to be handed over
41:48to Captain Lancaster and his crew.
41:53In fact, it was a disaster waiting to happen.
42:00The morning of the next day,
42:02the 111 was at 17,300 feet.
42:06The difference in pressure between the sealed hull of the jet
42:09and the thin atmosphere
42:10was climbing quickly to the half ton per square foot
42:13it would reach at 35,000 feet.
42:16This pressure was looking for a weakness,
42:18and it found it.
42:22For Culling, finding out what had happened that night
42:25is only the first step.
42:26No one had hidden from him what they'd done,
42:29but he knows that he has to go deeper
42:31to understand the reasons behind
42:32this horrific sequence of events,
42:35why the engineer did what he did,
42:36and whether this was an isolated incident
42:38or the symptom of a bigger problem.
42:42Accident investigation, certainly on aircraft,
42:44comprises two parts.
42:46The first part is what's happened,
42:47and that's usually relative to the easy bit.
42:50And the second part is why did it happen?
42:54Why did the engineer ignore procedure,
42:56bypass the technical manuals,
42:58and ignore helpful advice?
43:00Culling's search for the answers
43:02was in its own way revolutionary.
43:04If we talked to people without giving them a warning,
43:10we felt we'd get more information,
43:13because they'd be freer to discuss it.
43:16If we gave them a formal caution, as it were,
43:19we thought that they would dry up.
43:23Coffee?
43:24Yes, please.
43:24Great.
43:25How was the journey in?
43:26Oh, well, usual stuff.
43:27They decide to talk to the engineer
43:29well away from the hangar in a cosy hotel room.
43:32Well, thanks for coming in.
43:34To gain insight into the methods
43:36of the maintenance engineers,
43:37Culling then does something no one had done before.
43:41He brings in a behavioural psychologist.
43:46So, is the aircraft normally in the hangar
43:49when you're doing that?
43:51Psychologists had been used before
43:53to analyse why pilots make mistakes under pressure.
43:56It's a discipline called human factors.
43:59But in 1990,
44:01using human factors in engineering was unheard of.
44:05I wanted a professional slant
44:09on what is really psychological territory.
44:12I would hope that,
44:13as far as the shift maintenance manager was concerned,
44:17that it gave him extra confidence
44:19that we were trying to be even-handed
44:21and that we were trying to get to the bottom of it.
44:23You know, the parts catalogue.
44:27When you're getting the bolts out,
44:29do you go straight to the parts catalogue
44:31or do you just sort of...
44:32Not usually.
44:34No, if I've got a set of screws
44:36and I do the same screws,
44:37I just go and get them out of the carousel.
44:40Right.
44:40You find it's easier to do it visually?
44:43It was, in that case,
44:44easier to do it visually from the bolts you take now?
44:46Yeah.
44:47Yeah, cos they're the same bolts that come out,
44:48the same ones go back in,
44:49so same size bolts, there's no difference.
44:51And if it worked before, it must be the right bolts.
44:54Yeah, it's just replacing like with like, really.
44:55Yeah, cos it had been flying.
44:57We were somewhat horrified that they had...
45:02..that they had admitted those things to us
45:08because, after all, we were officially inverted commas
45:13and they were quite proud of them.
45:14We would have thought that had they used such practices,
45:17they would have kept very quiet about it.
45:19If I'd had to go check with the computers
45:23what bolts I needed and what parts
45:24and how to fit the thing,
45:26then there was a good chance
45:27it wouldn't have been flying at the time it was meant to be.
45:30Good, good.
45:33So, when you're...
45:36..doing the job now,
45:38you're an experienced engineer,
45:40it might not be by the book or the time,
45:44like you would train somebody who was new.
45:46No, we've been doing these things for years.
45:49Culling was stunned by what he was hearing,
45:51but there were more revelations to come.
45:58The engineer's dangerous approach
45:59was becoming clearer by the minute.
46:02You trusted your own knowledge
46:06better than the store supervisor's knowledge.
46:09Well, I'm an engineer.
46:10I got 7D bolts out, so I put 7D bolts back in.
46:13There's, you know, no problem with that.
46:18It's that simple.
46:20So you trusted that the aircraft had been flying,
46:24so therefore they must have been the right bolts?
46:26Yeah, that aircraft had done lots of hours with that windscreen.
46:30Their whole aim was to expedite work
46:36through their station.
46:37They had a lot of work come in.
46:39It was all done at night,
46:41and in many cases they had more work
46:44than they could reasonably handle.
46:46And they had devised little stratagems
46:48to get round that.
46:53Culling and the psychologists' insights
46:55made their way into the first draft of the report.
46:57It said that there were systemic faults
47:00in the maintenance procedure in Birmingham.
47:03But under pressure from British Airways lawyers,
47:05and because they hadn't carried out their investigation
47:08following normal procedure,
47:10the final report was forced to change its emphasis.
47:15Hour by hour, I mean the Treasury solicitor
47:19or whoever was advising the branch
47:23confirmed that under natural law
47:26it was unfair to use that information
47:30because we hadn't gone through the whole procedure.
47:33And so we had to remove that from the report.
47:39The investigators had never produced
47:41an accident report like it.
47:43Working with the psychologist,
47:46Culling developed a completely novel way
47:47of using human factors
47:49to explain why this accident happened.
47:51They uncovered pressures in the hangar
47:53that caused an otherwise proficient engineer
47:56to make potentially lethal mistakes
47:58whilst being certain he was doing the right thing.
48:00This psychological approach
48:03took air accident prevention to a new level.
48:08Through the sheer skill of the crew of BA-5390,
48:12as well as a small measure of luck,
48:1487 people are now still alive.
48:18As a consequence of this investigation,
48:20others may never have to go through the same ordeal.
48:24In the aftermath of the accident,
48:26the crew were treated as heroes.
48:28They received numerous awards
48:30and Alistair Acheson received
48:32the coveted gold medal for airmanship.
48:35Their colleagues also showed what they felt.
48:38One of the most moving things
48:42was to go back to Birmingham.
48:45As we walked into the airport,
48:47the whole of the airport stopped
48:50and all the ground staff
48:51and all the check-in girls
48:52and all that just stood and applauded
48:53as we walked through the building
48:54and it was really quite, you know,
48:57moving at the time.
48:58You sort of wanted to get out of the way
48:59so that you could sort of, you know,
49:02I don't really want to do this.
49:03It's like walking up the red carpet sort of thing.
49:05Their colleagues were applauding a team
49:07which had demonstrated
49:08the highest form of professionalism
49:10at every level.
49:11A cabin crew which worked as a team
49:13in extraordinary circumstances
49:15and the co-pilot,
49:16an outsider who took control
49:18and worked alone
49:19to bring them all safely down to earth.
49:23Each of the crew dealt with their experience
49:25in different ways.
49:27Tim Lancaster began flying again with BA
49:29just five months after the accident.
49:32He's retired from BA
49:33but loves flying so much
49:35he's now with another airline.
49:36You cannot say that.
49:38She'll shoot you.
49:39It was a special day
49:41when the first day I flew it.
49:42I decided, you know,
49:43that was what I was going to do.
49:44I was going to make an effort
49:44to go back to work and get better.
49:45So having made the decision
49:47the rest was easy.
49:49For Nigel,
49:50the man who ran to Tim's aid
49:51and held on to him for dear life
49:53the impact of that day
49:55was far more profound.
49:58I think about it every day
50:00and that is the truth.
50:02I think about it every single day
50:05in one form or another.
50:08Every single day
50:11it will affect me
50:12until the end of my days.
50:17Nigel, along with Simon and Sue
50:19no longer fly
50:20but John Heward
50:21is still with British Airways
50:23as a chief steward
50:24but even he isn't free
50:26of the memories of that day.
50:28They were bringing in
50:29another British Aerospace Aeroplane
50:31to where I worked in Birmingham
50:32and unfortunately
50:35that window was fitted
50:36from the outside
50:38and the layout of the cabin
50:40was identical
50:42and when I sat on it
50:44it all came back to you
50:46but for that reason
50:47I've gone back to work at Heathrow
50:49and fly long haul flights again
50:51because those aeroplanes
50:52have got no resemblance
50:53to the 111 at all.
50:55Alistair Acheson
50:56who is still flying
50:57for British Airways
50:58chose not to take part
51:00in this film.
51:04For each of the crew
51:05the experience will stay with them
51:07in different ways
51:08but common to them all
51:10is that on that day
51:11their numbers did not come up.
51:15Tim explained it very well actually
51:17and he said our names
51:18were on the page
51:19but we weren't at the top.
51:21And I think that was
51:22you know
51:22probably true.
51:53a bit.
51:55So
51:55I'm
51:55going to go.
51:56I think that was
51:56I don't know.
51:57He just came to me
51:57But he said the one who is
51:57I don't know.
51:57I don't know the name
51:58but he doesn't know
51:58He'll be like
51:58he said he helped us
51:58He's done.
51:58He gave me
51:59He said the name