Air Emergency (2003–…): Season 2, Episode 1 - Blow Out - full transcript

The pilot of a British airliner is partially sucked out of the cockpit after his windscreen blows out in flight.

It must be one of the most amazing
flying stories of all time.

An airliner full of passengers
out of control at 17,000 feet.

And the pilot is stuck
outside the plane.

(screams)

In the cockpit,

three frightened flight attendants
are clinging to his legs.

If he slips from their grasp,

the captain's body could
be sucked into the engine

and bring down the plane.

COPILOT: This is 5390...

At the controls,



a young copilot is battling to get
the plane to the nearest airport.

COPILOT: Mayday! Mayday! Mayday!....5390

The lives of 87 passengers and crew
hang by a thread.

People go through life thinking
"That'll never happen to me"

But you tend to go through life thinking
"It can"

I thought I was going to die.
I thought I was going to die.

This bizarre accident tested
the limits of human survival.

And the investigation that followed
not only exposed the mistakes behind it,

but led to new ways of preventing them.

For the crew
of the British Airways flight

from Birmingham, England,
to Malaga, Spain,

the 10th of June began
like any other day.

Old friends, about to do a job they loved.

Stewards Nigel Ogden
and Simon Rogers,



along with stewardess Sue Prince,

had worked together
on and off for years.

They're an experienced,
capable team that takes pride in it's work.

At Birmingham, all the cabin crew
and all the pilots,

they all knew each other,
we're all on first-name terms.

Simon was a good friend of mine,
anyway, cause we'd just go out

for a beer or a curry or whatever like that.

Everybody was friendly to everyone else.

The one new member of the group
was Alistair Atchison.

An experienced copilot,

he'd just driven down from Manchester
that morning.

Morning, Alistair.
-G'morning, Sir.

Come on in.

Tim Lancaster is captain.

He's been a commercial pilot
for 21 years.

Well, we'd better get started, eh?

Chief steward John Heward arrives
to give the crew their final briefing.

Morning, everyone.
-Morning

Right. Is that the first officer?

Yeah. Just down from Manchester.

Alright. Nice to see a new face.

OK. Today, Malaga!
Right, looking forward to this.

Nig, you can sit with me up front and talk rugby..

Sue, where would you like?
-Over the wing?

Right, so Simon?
You're at the rear.

Alright, just a few safety questions...
Nigel...

Before take-off, the copilot
performs a walkaround,

checking the outside of the aircraft
for anything wrong.

In the cockpit,
Captain Tim Lancaster reviews a log

of the maintenance carried out
on the plane the day before.

Everything okay?
Fine.

She's just come out of Maintenance,
by the look of it.

Nothing much, though.

Just changed the windscreen.

Many of the passengers
know the flight well,

and are looking forward
to a relaxed trip to Spain.

I was going to catch a plane
from Birmingham to Malaga

to meet my mum,
my sister and I were joining her there.

For a weeks holiday,
a "Girls Week"

I live in the south of spain
and 2 or 3 times per year

I come back and visit my
grandchildren and also my mother.

Everyone lives near Birmingham, so thats
the route I take: Malaga to Birmingham.

These unsuspecting passengers
and crew

were about to begin
an adventure of a lifetime.

You seem to have made yourself
comfortable.

Too right!

Ladies and gentlemen,
this is your Captain speaking.

My name is Tim Lancaster. Welcome aboard
this British Airways flight to Malaga.

-Unfortunatly our....

He seemed laid back and quite jovial,
really.

"It's a lovely day in Malaga, blue skies
sunshine, sit back and enjoy the flight."

-...sunny and we still expect
to get you there on time.

Birmingham Tower, Speedbird 5390,
we're ready to start and push.

MAN ON RADIO: Speedbird 5390,
cleared to start and push.

Ladies and gentlemen,
we're now going to take

you through our safety
procedures & equipment

As this information is for your benefit,
we ask you to watch and listen carefully.

Clear to start engines.

-Starting #2

Emergency exits are on both sides..

The stewardess showed you the
emergency exit and all the emergency gear

and of course nobody is really watching.

One chap was quite blase,
he was reading the Times

and people weren't really bothering
since we've all been on flights

and it's no big deal.

-...the air can be topped
up with the mouthpiece,

and there is a whistle
for attracting attention.

80 knots.

The BAC 1-11 was known
as the 'Jeep of the Skies',

a workhorse that was easy to maintain
and had a good safety record.

At 43 tonnes,

this pressurised hull is carrying
81 passengers and six crew,

and is now climbing to 23,000 feet.

In just over two hours
they should be in Spain.

Only a catastrophic accident

could bring this plane
out of the skies.

Alistair, I can see my house from here.

Two minutes into the climb
the pilots switch on the autopilot.

Tim Lancaster takes off his shoulder
straps and relaxes into the flight.

I went into the flight deck

to ask Tim and Alistair

what they would like to drink.

Would you gentlemen like a tea?
Please. The usual.

Milk, one sugar, please.

And I said, "Your breakfast's on.
It'll only be a few minutes."

Now, almost 13 minutes
after take-off, and at 17,300 feet,

they're just 5,000 feet
from their assigned altitude.

But then, in a split second,
everything changes.

[RATTLING SOUND]

[LOUD THUD AND SUCKING SOUND]

[ALARM BLARES]

-Aargh!

With a huge explosion, the captain's
windscreen blows out into the sky.

Almost immediately
a white fog forms.

PANICKED SCREAMS

A sort of really intense,
stomach/body-shaking thud.

[SCREAMING]

WOMAN: We were just diving, really.

Then we started to judder,
like this.

And I was a bit stunned.
I thought, "Oh, God, it's a bomb."

ALARM BLARES

Alistair, the copilot,
is suddenly fighting for control

in a 350m/h wind.
(563 km/h)

There's no time to think
about the captain.

who's been blasted out of the window

by pressurised air
escaping from the aircraft.

[VOOP VOOP VOOP VOOP]

The rushing wind pins Captain
Lancaster to the roof of the cockpit.

Inside, his legs have jammed
the control column forward,

disconnecting the autopilot and
pushing the plane down into a dive.

[ALARMS]

Alistair Atchison needs all of his
flying experience now, he's on his own.

The captain's body is
pinned to the outside of the jet

as it hurtles down from 17000 feet.

The throttles are jammed forwards, increasing
the speed to nearly 400 mph. (643 km/h)

Copilot Alistair Atchison
has to take command.

While he fights to bring the plane
under control,

steward Nigel Ogden

can see his captain
is being sucked out of the aircraft.

NIGEL OGDEN: And I looked in -

the flight deck door
was resting on the controls,

and all I could see
was Tim out the window.

ALARM BLARES

I jumped over, put one foot
in the captain's footwell,

and the other one
was down the side of his seat.

I just grabbed him
before he went out completely.

Nigel Ogden holds onto the captain
for dear life.

Outside, a 390mph (627 kmh) blast
of wind at -17 degrees Centigrade

smashes into Tim
Lancaster's body.

The tornado in the cockpit is
giving Atchison major problems.

Mayday! Mayday! Mayday!
(calls out inaudibly)

Air Traffic Control can
hear his cries for help

but the storm rushing through
the cockpit drowns out their replies.

[INAUDIBLE]

The captain's feet are still
pushing against the control column

and Alistair is struggling to
get full control of the plane.

He's now diving through some of
the busiest air lanes in the world,

with the added danger
of a mid-air collision.

[SCREAMING]

From the cabin, lead steward
John Heward

sees the chaos in the cockpit
and does what he can to help.

I looked up, and there was Nigel

sort of hanging across the seat
in the flight deck.

In front of me the flight deck door
had fallen forwards

and trapped itself
between the actual door frame

and the throttles of the aircraft.

So I literally stamped on it twice

and it literally broke
into three or four pieces.

Behind,
on the wall of the flight deck,

there is a spare seat for anybody
to observe the flight, or whatever,

and I thought, "If I put my arm
through the seatbelt there

"I can grab both of them,

"and at least we've got
some sort of anchor point

"inside the aircraft."

(grunts)

Alistair, who's never flown
with this crew before,

has to leave them
to their own devices

and focus on getting the plane
to safety.

He now has control of the throttles.

John and Nigel have wrenched
the captain's feet away

from the control column.

But instead of slowing down,

Atchison decides to continue
the rapid descent.

It will quickly take him out of
the way of any other air traffic

and take him to a lower altitude

where oxygen equipment
won't be needed.

Staying to long at a high altitude
risks oxygen starvation.

And this older aircraft

is not fully equipped with oxygen
for all the passengers on board.

The airspeed indicator
goes into the red.

[SCREAMING]

Brace positions! 'ands behind your 'ed!
Everybody take the brace position!

In the cabin, the two other stewards

Sue Prince and Simon Rogers
are trying to prepare the passengers

for what they hope will, at worst,
be an emergency landing.

ATCHISON: Speedbird 5390.
Mayday, mayday, mayday!

Emergency. Depressurisation.

They've dived to 11,000 feet
in just 2.5 minutes.

But as they level out and slow
down to 170mph, (273 kmh)

the captain's body
is no longer pinned to the roof

and slides round
to the side of the plane.

Descending to flight level 1-0-0.
Radar heading 1-9-5

Working his way
from the back of the cabin,

steward Simon Rogers

now catches sight of the chaos
in the cockpit for the first time.

PASSENGER: Can you
let us know what's going on?

Now the aircraft had
got to flying fairly level.

Simon came up from the back.

Nigel was beginning to get
really achy now with his arms.

I knew he wasn't going to let go

unless he was sure
Tim wouldn't fly out of the window.

We all had fear in our eyes.
We were all worried sick.

We thought, either Tim's gonna die
or we're gonna die. You know.

That was going through me mind.

But it was up to Alistair then,
and it was up to us three -

Simon and John and myself,

to hold on to grim death.

Mayday! Mayday! Mayday!

All I remember
is Tim's arms flailing out.

His arms seemed about 6 foot long.

And I'll never forget,
his eyes were wide open,

his face was hitting
the side of the sidescreen.

But he didn't blink.

And I...I thought to myself,
and I said to John,

"I think he's dead.

I think he's dead."

And I said, "You and Si
will have to hold on.

"I can't hold on anymore.

"I've lost the feeling in me arms."

We decided to put Simon...

I said to Simon,
"You sit in that jump seat

"and fasten yourself in."

WIND HOWLS

With Simon sitting in the seat,

we'd freed Tim's legs from between
the control column and the seat.

So we hooked his feet over the back
of the captain's seat,

then Simon literally
put his hands on the top

so he was holding his ankles down.

Come on! Fight! FIGHT!

Hey! Look, what's going on?

We're gonna be alright.
But... I think the Captain's dead.

[GASP]

I just couldnt believe it because he'd
just told us what a lovely day it was

y'know, blue skies,
sunshine.. relax and enjoy the flight

and the next minute, he's dead?

Simon and Alistair now faced one
of their most difficult decisions -

what to do with the lifeless body
of the captain.

No words are said,

but for a moment the
thought passes between them

that the best thing
would simply be to let it go.

(strains)

No! Can you hold on to him, please?

But Alistair's order isn't simply
an act of compassion.

STANLEY STEWART: Releasing the body
at the position it was in,

it would've gone close
to the upper area of the wing.

It could've damaged
the leading edge of the wing.

Had it gone over the wing,
it could've gone into the engine.

A lot of damage could've been caused
by releasing the body.

I think it was
a very sensible decision

to try and keep him where he was.

Alistair has managed to get down
to 11,000 feet.

Without the captain to help,

he's operating the plane systems
from memory

and shepherding it around Heathrow...

..some of the most congested airspace
in the world.

Seven minutes out of contact
with the ground,

he's able to hear the voice of Air
Traffic Control for the first time.

Requesting radar assistance
onto the nearest airfield, please.

Speedbird 5390, roger.

Can you accept landing
at Southampton?

Speedbird 5390,
I am familiar with Gatwick.

Would appreciate Gatwick.

Alistair wants to land
at Gatwick Airport,

as he's flown there
many times before.

But Southampton is nearer,

and even though
he's never flown there before,

he knows he has to get down fast.

I am on 150 knots.

Requesting radar assistance
into Southampton.

When you're going to an airport
that you're not used to,

you normally have charts,
letdown plates, that kind of thing,

that you can read up on

and learn something
of the airport you're going to.

But he knew nothing of Southampton.
He hadn't been there.

He had no charts -
everything had gone out the window.

There was no letdown plates
to look at the approach, etc.

All the maps and charts blew out
of the window with the captain,

and only the air traffic controller
can guide Atchison.

He turns towards Southampton.

Southampton, this is Speedbird 5390.
Do you read?

MAN ON RADIO: Speedbird 5390,
good morning.

Identified on handover
from London Radar,

six miles west
of Southampton Airfield.

What is your passing level?

Roger, sir.

I am not familiar with Southampton.

Request you shepherd me
onto the runway.

When he spoke,
he was obviously stressed.

It sounded as if he was under
a fair bit of pressure.

What is your number of persons
on board?

We have 84 passengers on board,

and I think that will be all
until we are on the ground.

Roger. That's copied.

I've been advised it's
pressurisation failure.

Is that the only problem?

Uh...negative.

Uh...

..the captain is half out
of the aeroplane.

I understand....
I believe he's dead.

Roger, that is copied.

My feeling was,
when he told me what was going on, it was

one of disbelief,
because it doesn't actually happen.

It's one of these things
that you see in films,

that happens in films,
but it doesn't happen in real life.

And it was...sort of, the hairs
on the back of the neck go up

and there's this feeling down the
spine, the tingle down the spine.

And you think,
"No, it's not for real."

But it's got to be.

Flight attendant holding on to him.

But requesting emergency facilities
for the captain.

I think he is dead.

Affirm - what is your passing level?

Leaving flight level - 5,500 feet
on 10/90.

Roger. That's copied.

I'll give you a bit more space,

then I'll turn you onto a heading
of 1-8-0.

Yeah, it's a full emergency...

Rundle contacts Emergency Services
at the first opportunity.

..how many on board,
but I'll let you know.

SIREN WAILS

Could you confirm that

the runway at Southampton
is acceptable for a 1-11?

Yes, it is acceptable for a 1-11,

and I'll give you
the figures shortly.

As long as we have
at least 2,500 metres, I'm happy.

I'm afraid we don't have
2,500 metres.

Neither do Bournemouth.

We have a maximum of 1,800 metres.

5390...

Atchison is concerned that the plane
is above its maximum landing weight,

being full of fuel
for the journey to Malaga.

And the BAC 1-11 can't dump fuel.

If the runway isn't long enough,
he faces more problems.

Whether the aircraft could actually
stop on the runway,

or whether the tyres would burst,

or whether he'd go off
the end of the runway -

that's obviously what he was worried
about when asking for 2,200 metres.

5390, thank you very much.

We are...

..three greens and, uh...flaps 45.

So we are set for approach,
but make it, please, very gentle.

Yes, I will indeed.
You are No.1 traffic.

If you think about it,
all the airline pilot training

is done with two pilots,
both compos mentis, in the cockpit -

one flying the aeroplane and the
other doing the emergency drills.

So what you had was the captain
hanging out the window,

at least one person
hanging onto his legs,

and Alistair flying the aeroplane,
with nobody else to talk to.

Speedbird 5390
is nine miles from touchdown.

You're clear to land.

Wind indicates 0-2-0 degrees
at 1-4 knots.

Descend to height 1-5-0-0 feet.

QFE is 1-0-1-7.

Roger, sir.
Descending to 1,500 feet.

Talk me down all the way.

I need all the help I can get.

Roger. You'll be able to stop
the aircraft on the runway

and evacuate the aircraft
on the runway.

He must've been about
six or seven miles from touchdown.

And obviously at that point,
I kept talking

until he was happy
he could see the runway

and was happy to continue
looking out the window

and land the aeroplane.

Um, at the point he said
he was visual with the runway,

I effectively stopped talking.

ATC: You need not
acknowledge unless requested.

It will be an uninterrupted
talkdown.

But feel free to interrupt
if you feel you need to.

5390, thank you very much.

I have the runway in sight.

Thank you. You are clear to land.

Do you wish me to continue
with any further information?

Negative.

32 minutes after take-off,

with 81 terrified passengers,

a nearly full fuel tank and the
captain blasted out of the window,

Alistair Atchison attempts the most
difficult landing of his career.

(all applaud)

(sobs quietly)

SIREN WAILS IN DISTANCE

At 8:55am,

Flight BA5390
makes a perfect landing

at Southampton airport.

Immediately, emergency vehicles
surround the plane.

Firefighters remove the body
of the captain

and lead the passengers
and crew away.

I remember seeing the co-pilot,
the man who really....

if it wasn't for him we'd have
been on the other side by now

and, uh, he's walking down the runway..

very slowly, shaking his head,
and he's got an ambulanceman

walking with him with his arm
around the shoulders of the co-pilot

and the co-pilot was shaking his head,
as if

I remember that distinctly,
and I don't know why, but I do.

Alistair Atchison has carried out
a remarkable piece of flying,

almost unprecedented
in aviation history.

He has had to pilot his plane
without his captain,

who has undergone physical stresses

that nobody
could have been expected to survive.

I think these extreme conditions,

no-one expects to occur
in their lifetime.

His survival time
must've been measured

in no more than tens of minutes

as he became colder and colder

and his body systems
began to shut down.

Tim Lancaster's body was subjected
to a two-pronged assault.

(man screams)

The physical violence that his body
suffered being blown out of the plane

and the extreme cold and lack
of oxygen at 17,000 feet.

Every thousand feet of altitude

causes the temperature to drop
by two degrees Centigrade.

So the temperature of the outside
of the plane

would've been around
-17 degrees Centigrade.

The extreme wind chill also meant his
body was losing heat very rapidly.

He would've lapsed
into semi-consciousness

and then unconsciousness,

and as his core body temperature fell,
he would've finally died

as a result of the excessive cold
in that environment.

Despite the trauma that
Captain Lancaster's body suffered,

there was one final twist
to his story.

It's only once I've been here -
that was 10 years ago.

In the Oxfordshire countryside,
John Heward and Nigel Ogden

are visiting
one of their crew members

who shared
their horrific experiences.

Here he is.

Hey, guys!

John, how are you, nice to see you.
Nice to see you, mate.

Nige. Come in, come in.

..and you've got to pretend...

The captain of that fateful flight,
Tim Lancaster

somehow survived his horrific ordeal.

There were no fatalities
on BA5390.

Yeah, that's it.
A three-day cruise across there...

As his frozen, lifeless body
was removed from the plane,

nobody thought that Tim
could have survived such punishment.

But remarkably,
he was slowly starting to emerge

from his horrific adventure.

MAN: Tim, can you hear me?

TIM: I regained some consciousness
on the ground at Southampton,

because I remember
big red and white things,

which were obviously
fire engines and ambulances.

Not people and not conversation.

And then my next clear,
lucid thoughts

were in hospital in Southampton.

MONITOR BEEPS

Over the next few days,

all the bits eventually arrived back
in my, sort of, consciousness

and I put the jigsaw together and,
you know,

played the whole story for myself.

And, uh...understood
what had happened.

CRASHING SOUND

ALARM BLARES

I heard a big bang,

a noise of all the air escaping.

But I remember watching
the windscreen

move away from the aircraft,

then it had gone, like a bullet,
disappeared into the distance.

And I think there was an even bigger bang,
there WAS an even bigger bang...

CRASHING SOUND

(man screams)

..and I was very conscious
of going upwards.

And, uh, the whole thing became
completely surreal,

as it would.

I was aware of being outside
of the aeroplane,

but that didn't really bother me
a great deal.

What I remember most clearly
is the fact I couldn't breathe,

because I was facing
into the airflow.

And I turned around,
actually turned my body around,

I was sort of looking back along the
top of the aircraft at that stage,

and I could breathe there.

Yes, I remember that.

I can remember seeing
the tail of the aircraft,

the engines going round.

And then I don't remember much
at all.

Memory stopped at that point.

I went down there last year, but
they've changed the airport...

I'm glad I did hold on, because
Tim was alive.

I mean, he's a very strong man.

He must have been, to survive that.

I wouldn't have been able
to survive it.

TIM: That's all very dramatic.

It is. Look...

Tim Lancaster's survival
was little short of miraculous.

He'd been minutes away from death.

It was Alistair Atchinson's flying
that saved his life.

His quick thinking in getting
the plane to the ground

in only 22 minutes

saved Lancaster from dying
from the effects of exposure.

And by pure chance,

the physical trauma he suffered
was limited.

It included a bone fracture
in his right arm and wrist,

a broken left thumb,
bruising, frostbite and shock.

Remarkably, within five months,

Tim Lancaster had made a full
recovery and was flying again.

Speedbird 5390...

Of course,
the captain wasn't the only one

to go through a horrific experience.

Battling with the controls while a
tornado raged through the cockpit,

was something no commercial pilot
could be trained for.

The few pilots who are able
to understand the experience

of Atchison and his crew

include these young
Royal Air Force trainees.

They're being put through
a simulation

of an explosive decompression

in this hyperbaric chamber.

It duplicates the effect of a
window blowing out at 25,000 feet.

Climbing to 8,000 feet
at 4,000 feet per minute.

The atmospheric pressure
is initially set to 8,000 feet.

This is the pressure
inside the sealed cabin

of most commercial aircraft.

Anyone can survive this
for many hours with no ill effects.

Any higher than that
and the experience is very different.

Students, listen in. Will all students
please indicate with a clear thumbs-up

that they're ready for rapid decompression.

8 thumbs. Rest your thumbs.

MAN: Stand by for rapid
decompression.

In five, four, three, two, one -
now.

PRESSURE RELEASES

The mist in the hyperbaric chamber

is identical to the fog formed
when the window blew out on BA5390.

At the instant
of rapid decompression,

the air in the cabin can no longer
hold onto its water vapour,

which is then released
into the atmosphere as fog.

...stable at 25,000 feet. You are
clear to commence hypoxia training.

commence hypoxia training all students

..7 and 8...

Once the fog clears,

the lack of oxygen at that height
begins to tell.

Alright, start copying these
sheets in the right-hand margin.

Without oxygen,
at first we begin to see

a reduction
in their reaction speed.

we see personality changes,
much like when intoxicated with alcohol

some students become euphoric, some
quite subdued, some develop forgetfulness.

have a look at the ugliness
of your colleaugues faces

see if they get any prettier whilst you're
becoming hypoxic and carry on with the task

We see increasingly impaired
performance in our students.

Thinking is slowed

and their reaction speed becomes
increasingly slowed,

until they begin to develop
sort of lapses of concentration,

falling into unconsciousness,
and finally death,

if their oxygen supply
is not re-established.

your blood is no longer carrying
as much oxygen as it was,

this is all about you experiencing
your personal symptoms

and having others observe the symptoms in you

Flying alone,
battling nearly 400m/h (643 kmh) winds,

and defeating the possibility
of oxygen deprivation,

Alistair Atchinson's achievement
in saving flight 5390

was outstanding.

Even as the crisis was unfolding,

accident investigators
were rushing to Southampton

to find an explanation.

On the ground
at Southampton Airport,

the search for clues begins.

Initial investigation
shows no distortion

to the frame of the windscreen,

so this rules out a problem
with the structure.

The fact that
there are no shards of glass

also discounts a bird strike.

Stuart Culling,

senior investigator with the
Air Accident Investigation Branch,

has little to go on.

STUART: Windscreen was missing,

there was a certain amount
of blood around.

There were some minor dents
and scrapes on the fuselage,

as you'd expect
if the window had gone past.

And really that was about it,

apart from a lot of paper
scattered around inside.

One of his first clues comes from
the log recovered from the plane.

He knows the plane had been serviced
just the day before,

and that a windscreen
had been replaced.

He immediately pays a visit to the
British Airways maintenance hangar

at Birmingham.

I wanted to find out exactly
what had happened to the aircraft

before it took off.

I'd arranged that I should talk
to the shift maintenance manager

who'd fitted the window.

There was a slight problem there,
because he'd been on night duty,

and consequently
he had finished his shift

at roughly the same time as the
windscreen came out of the aircraft,

he wasn't in a fit state to be
interviewed - he needed to sleep.

Stuart Culling...
MAN: Good morning.

I was expecting you.
Yes. Good.

Thank you very much.
Is this the hangar in question?

This is the main hangar...

So, in the meantime,
I looked around the facility.

I made sure that any paperwork
and any records of the aircraft

had been identified and taken away,

so they couldn't be accessed
by anyone else,

and waited until he came in.

Hello. I'm from the AAIB.

And this is my colleague.

What I'd like to do today,

is just find out what went on
during that shift,

and how it went.

Did you notice anything
about the window itself?

Any stress marks
that were worrying you?

My first conversation
with the shift maintenance manager

was relatively general,

because at that stage, we had
no evidence that was relevant.

..you didn't delegate it
to somebody else, then...

Stuart, there's a phone call
for you.

Oh, right. Would you mind
if I took this? I'll come back.

So I took the call,

and found it was information
about the windscreen,

which had been found near Didcot.

There were something like 30 bolts
found with it,

most of which were one size short
in diameter,

one size too small in diameter.

It was a crucial error.

On some planes, windscreens
are fitted from the inside

and use the internal pressure inside
the cabin to keep them in place.

But on the 1-11, the windscreen
is bolted on from the outside.

Any weakness in the bolts could mean

that the pressure inside the plane
would blow the windscreen out.

It appears Culling has very quickly
found the mistake,

and the guilty man.

Um, I've had some news
which I think is very relevant.

I've heard from my colleagues
who are working on the bolts,

they tell me
they're the wrong bolts.

They're the wrong diameter.

Um...no, that's not possible.

They're exactly the same bolts
that I took out of there.

He's a professional man.

He's very keen on doing things,
to his mind,

in the interests of the company,

and he's suddenly told
that he's put a windscreen in

using bolts of the wrong size,
and he's absolutely shocked.

I can show you. I can show you
the bolts I have out there.

One thing that came out was,

he said the old bolts went into
a wastebin in the hangar

where he did the job,

and they may still be there.

So we rushed across to the wastebin

and found something like
80 discarded bolts.

They'll be in here.
This is where I put them.

These are the...
These are the bolts.

These are the ones you checked
against the new ones?

That's right. Yeah.
From the carousel?

It was really excellent evidence.

Gold, as far as I was concerned.

Well, I'll take these away...

Okay?

By comparing the maintenance manual
to what the engineer had told him,

Culling is quickly able to identify
the first part of the sequence -

what went wrong the previous night

when the window of the BAC 1-11
had been replaced.

We went through the whole
chain of events that had occurred,

and we found that...

there were something like
13 different anomalies,

which led to the fitting
of the bolts.

And had any of these
caused him to think,

the sequence of events
would not have continued

and there wouldn't have been
an accident.

The engineer had come early
into his shift.

And at about 4am had gone to work

removing the old windscreen
from the plane.

The hangar was full,

and the plane had been pushed
against the hangar door,

which made the windscreen
hard to reach.

Stretched across the fuselage,

he had problems
controlling his screwdriver.

The windscreen that he had taken out

had itself been fitted
with the wrong length bolts.

But they were still strong enough
to hold the screen in,

and it survived without a hitch
for four years.

But he was a conscientious engineer,

and he decided that he would replace
the old bolts with new ones

when he installed the new screen.

He chose not to go
to the parts catalogue

and look up the exact bolts
he needed.

Instead he went
straight to the parts store.

Good morning.
Morning.

There, he matched by eye

new bolts with the ones
he'd taken out of the screen.

His eye match was good,

and he found a few fresh bolts
of exactly the same type in a drawer.

I'm after 90 7Ds.

I'm doing a windscreen on a 1-11
over there and need some bolts.

8Ds on a 1-11.

Well, no, these are 7s.
I've just taken it out.

We haven't got any 7s anyway.
Okay.

The store manager knew which bolts

the engineer should have been
looking for.

But the engineer chose to ignore
his advice.

Instead he drove to the other side
of the airport

to find a match for his bolts.

It was now about 5:15am,

and in a dark corner of the hangar,

he continued to search for new bolts

identical to the ones
he'd taken out of the plane.

But in the gloom,
his luck finally ran out.

He thought they matched,
but they didn't.

He picked bolts that were just over 200th
of inch (0.127 mm) too narrow for the job.

Returning to the 1-11,

he stretched over the plane
and began fitting these new bolts.

Working at an angle,

he couldn't see that the new bolts
didn't fit correctly.

Signing off at 6:00am,

the engineer had managed
to get his work done in time.

The plane was now ready
to be handed over

to Captain Lancaster and his crew.

In fact, it was a disaster
waiting to happen.

The morning of the next day,

the 1-11 was at 17,300 feet.

The difference in pressure between
the sealed hull of the jet

and the thin atmosphere

was climbing quickly to the half tonne
per square foot (7 psi) it would reach

at 35,000 feet.

This pressure was looking for
a weakness...

..and it found it.

LOUD THUD

For Culling, finding out
what had happened that night

is only the first step.

No-one had hidden from him
what they'd done.

But he knows that he has to go deeper
to understand the reasons

behind this horrific
sequence of events -

why the engineer did what he did,

and whether this was
an isolated incident

or the symptom of a bigger problem.

CULLING: Accident investigation,

certainly on aircraft,
comprises two parts.

First part is - what's happened?

That's usually
relatively the easy bit.

The second part is -
why did it happen?

Why did the engineer
ignore procedure,

bypass the technical manuals,

and ignore helpful advice?

Culling's search for the answers
was in its own way revolutionary.

If we talk to people
without giving them warning...

..um, we felt we'd get
more information.

Because they would be freer
to discuss it.

If we gave them a formal caution,
as it were,

we thought that, uh...
they would dry up.

Coffee?
MAN: Yes, please.

How was the journey in?
Oh, the usual stuff..

They decide to talk to engineer
well away from the hangar,

in a cosy hotel room.

Well, thanks for coming in...

To gain insight into the methods
of the maintenance engineers,

Culling then does something
no-one had done before.

He brings in
a behavioural psychologist.

Is the aircraft normally in the
hangar when you're doing that?

Psychologists had been used before

to analyse why pilots make mistakes
under pressure.

It's a discipline called
'human factors'.

But in 1990, using human factors
in engineering was unheard of.

I wanted a professional slant on

what is really
psychological territory.

I would hope that as far as

the shift maintenance manager
was concerned

that it gave him extra confidence.

That we were trying to be even-handed,

and trying to get
to the bottom of it.

You know, the parts catalogue -

um, when you get the bolts out,

do you go straight
to the parts catalogue,

or do you just sort of, um...?

Not usually.
Right.

If I've got a set of screws,
and they're the same screws,

I just go get them
out of the carousels.

You find it's easier to do it
visually?

It was in that case,
easier to do it visually?

Yeah, 'cause the same bolts
that come out,

are the same ones go back in.

Same size bolts.
There's no difference.

And if worked before,
it must be the right bolts?

Just replacing like with like.
Yeah, because it had been flying.

We were somewhat horrified
that they had...

..that they admitted.....
those things to us.

Because, after all, we were
'official', in inverted commas,

and they were quite proud of them.

We would've thought
that had they used such practices,

they would've kept very quiet
about it!

If I'd had to go check
with the computers

what bolts I needed, what parts,
and how to fit the thing,

there was a good chance
it wouldn't have been flying

at the time it was meant to.

Good. Good.

So, when you're...

..doing the job now -
you're an experienced engineer -

it might not be 'by the book'
all the time,

like you would train somebody
who was new?

No. We've been doing these things
for years.

Culling was stunned
by what he was hearing.

But there were more revelations
to come.

The engineer's dangerous approach
was becoming clearer by the minute.

You trusted your own knowledge

better than the store supervisor's
knowledge?

Well, I'm an engineer.

I got 7D bolts out,
so I put 7D bolts back in.

That's why...
No problem with that.

It's that simple.

So, you trusted that
the aircraft had been flying,

therefore they must have been
the right bolts?

Yeah. That aircraft had done
lots of hours with that windscreen.

Their whole aim was to expedite work

through the, uh,
through their station.

They had a lot of work coming in,
it was all done at night,

and in many cases,

they had more work
than they could reasonably handle.

And they had devised little
stratagems to get around that.

Culling and the psychologist's
insights

made their way into the first draft
of the report.

It said that there were
systemic faults

in the maintenance procedure
in Birmingham.

But under pressure from
British Airways' lawyers,

and because they hadn't carried out
their investigation

following normal procedure,

the final report was forced
to change its emphasis.

Hour by hour,
I mean, the treasury solicitor,

or whoever was advising the branch,

confirmed that under natural law,

it was unfair
to use that information,

because we hadn't gone
through the whole procedure.

So we had to remove that
from the report.

The investigators had never produced
an accident report like it.

Working with the psychologist,

Culling developed a completely
novel way of using human factors

to explain why
this accident happened.

They uncovered
pressures in the hangar

that caused an otherwise
proficient engineer

to make potentially lethal mistakes,

whilst being certain
he was doing the right thing.

This psychological approach

took air accident prevention
to a new level.

Through the sheer skill
of the crew of BA5390,

as well as a small measure of luck,

87 people are now still alive.

As a consequence
of this investigation,

others may never have to go through
the same ordeal.

In the aftermath of the accident
the crew were treated as heroes.

They received numerous awards,

and Alistair Atchison received the
coveted gold medal for airmanship.

Their colleagues also showed
what they felt.

JOHN HEWARD: One of the most moving
things was to go back to Birmingham.

As we walked into the airport,
the whole of the airport stopped.

All the ground staff,
all the check-in girls, etc,

just stood and applauded
as we walked through the building.

It was really quite, you know,
moving at the time.

You sort of wanted
to get out of the way, so...

You know,
"I don't really wanna do this."

Walking up the red carpet
sort of thing.

Their colleagues
were applauding a team

which had demonstrated
the highest form of professionalism

at every level -

a cabin crew which worked as a team
in extraordinary circumstances.

And the copilot - an outsider
who took control and worked alone

to bring them all safely down
to earth.

Each of the crew dealt with
their experience in different ways.

Tim Lancaster began flying again
with B.A.

just five months after the accident.

He's retired from B.A.,

but loves flying so much
he's now with another airline.

TIM: It was a special day
when I first flew.

I decided to make an effort to
return to work and get better,

so having made a decision,
the rest was easy.

(screams)

For Nigel, the man who ran to Tim's
aid and held onto him for dear life,

the impact of that day
was far more profound.

NIGEL: I think about it every day.

And that's the truth.

I think about it every single day.

In one form or another, you know?

Every single day.

Um, it will affect me
till the end of my days.

Nigel, along with Simon and Sue,
no longer fly.

But John Heward is still with
British Airways as a chief steward.

But even he isn't free
of the memories of that day.

They were bringing in another
British Aerospace aeroplane

to where I worked in Birmingham,

and unfortunately, that window
was fitted from the outside.

And the layout of the cabin
was identical.

And when I sat on it,
it all came back to you.

Um, but for that reason
I've gone back to work at Heathrow,

fly long-haul flights again.

Because those aeroplanes have got
no resemblance to the 1-11.

Alistair Atchison, who is still
flying for British Airways,

chose not to take part in this film.

For each of the crew,

the experience will stay with them
in different ways.

But common to them all
is that on day,

their numbers did not come up.

Tim explained it very well,
actually.

He said, "Our names were on the
page, but they weren't at the top."

And I think that was, you know,
probably true.