Original subtitles

ATTENDANT: Ladies and gentlemen, we are starting our approach.

PILOT: We lost both engines.

ATTENDANT: --the mask over your nose. emergency descent.

PILOT: Mayday, mayday.

ATTENDANT: Brace for impact!

[music playing]

MAN: He's gonna crash!

[music playing]

NARRATOR: June 10th, 1990.

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

and the pilot trapped outside of the plane.

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.

At the controls, a young copilot is battling to get the plane

to the nearest airport.

ALASTAIR ATCHISON: Mayday, mayday, mayday.

London, this is Speedbird 5390.

[music playing]

NARRATOR: The lives of 87 passengers and crew

are in serious and immediate danger.

[music playing]

A lot of people go through life thinking,

it'll never happen to me, but you tend to go

through life thinking, it can.

I said, I thought I was gonna die, mother.

I thought I was gonna die.

NARRATOR: This accident and the investigation that follows not

only expose the mistakes behind it,

but lead to new ways of preventing them.

[music playing]

You're welcome.

NARRATOR: For the crew of the British Airways flight

from Birmingham, England to Malaga, Spain,

the tenth of June began like any other day.

Old friends about to do a job they love.

[music playing]

You remember that?

SIMON ROGERS: Yeah, but I'm not doing--

NARRATOR: Flight attendants Nigel Ogden,

Simon Rogers, and Sue Prince have worked

together on and off for years.

They're an experienced, capable team

that takes pride in their work.

[music playing]

The one new member of the group is Alastair Atchison.

An experienced copilot, he has just driven down

from Manchester this morning.

[music playing]

SIMON ROGERS: Would you go to anything special?

Not really.

It's just--

Morning, Alastair?

Come with me.

NARRATOR: Tim Lancaster is the Captain.

He has been a commercial pilot for 21 years.

Well, we better get started, eh?

OK, OK.

Malaga.

Right.

Looking forward to this.

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

Sue, where would you like?

Over the wing.

OK So, Simon, you're at the rear.

All right, now just a few safety questions.

Nigel.

NARRATOR: Before takeoff, the copilot

performs a walk-around, checking the outside of the aircraft

for anything wrong.

[music playing]

In the cockpit, Captain Lancaster

reviews a log of maintenance carried out

on the plane the day before.

Everything OK?

Fine.

She just come out of maintenance by the look of it.

Nothing much though.

Just changed the windscreen.

NARRATOR: Many of the passengers know

the flight well and look forward to a relaxed trip to Spain.

I was going to catch a plane from Birmingham

to Malaga to meet my mom.

My sister and I were joining her there for a week's

holiday, a girl's week.

I live in the South of Spain, and two or three times

a year, I come back to see my grandchildren and also

my mother.

So everyone lives near Birmingham,

so that's the route I'd normally take, Malaga to Birmingham.

NARRATOR: These unsuspecting passengers

and crew are about to face a series of terrifying events.

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.

Unfortunately, it--

He seemed laid back and quite jovial, really.

Why, it's a lovely day in Malaga.

Blue skies, sunshine.

Sit back and enjoy the flight.

TIMOTHY LANCASTER (OVER INTERCOM):

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

Birmingham tower, Speedbird 5390.

We're ready to start and push.

AIR TRAFFIC CONTROLLER: Speedbird 5390,

clear to start and push.

[music playing]

80 knots.

[music playing]

NARRATOR: The BAC 111 is known as the Jeep of the skies,

a workhorse that is easy to maintain

and has a good safety record.

[music playing]

At 43 tons, this pressurized 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 can bring

this plane out of the sky.

Alastair, I can see my house from here.

[music playing]

NARRATOR: Two minutes into the climb, the pilots

switch on the autopilot.

Captain Lancaster takes off his shoulder straps

and relaxes into the flight.

Now, I went into the flight deck

to ask Tim and Alastair what they would like to drink.

You gentlemen like a tea?

Please, the usual.

Milk, one sugar, please.

And I said, your breakfast is on.

It'll only be a few minutes.

NARRATOR: It's now almost 13 minutes after takeoff,

and at 17,300 feet, they're just 5,000 feet

from their assigned altitude.

But in an instant, everything changes.

[music playing]

With a huge explosion, the Captain's windscreen

blows out into the sky.

Almost immediately, a white fog forms.

That's that really intense stomach, body-shaking thud.

STEPHANIE JENKINS: We were just diving, really.

And then we started to judder like this.

And I was a bit stunned.

I thought, oh, god, it's a bomb.

[alarm blaring]

NARRATOR: Alastair Atchison, the copilot,

is suddenly fighting for control in a 350 mile-an-hour wind.

There's no time to think about the Captain, who has been

blasted out of the window by pressurized air

escaping from the aircraft.

[alarm blaring]

The rushing wind pins Captain Lancaster

to the roof of the cockpit.

[music playing]

Inside, his legs have jammed the control column forward,

disconnecting the autopilot and pushing

the plane down into a dive.

[music playing]

Atchison needs all his flying experience now.

He's on his own.

[music playing]

While he fights to bring the plane under control,

flight attendant, Nigel Ogden, sees his Captain 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 blaring]

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.

NARRATOR: Ogden holds onto the Captain for dear life.

[alarm blaring]

Outside, the air temperature is nearing zero degrees Fahrenheit

as a 390 mile-an-hour blast of wind smashes

into Tim Lancaster's body.

The extreme force of the wind in the cockpit

is giving Atchison major problems.

Mayday, mayday, mayday.

London, this is Speedbird 5390.

NARRATOR: Air traffic control can hear his cries for help,

but the wind rushing through the cockpit

drowns out their replies.

Mayday.

London, this is Speedbird 5390.

NARRATOR: The Captain's feet are still

pushing against the control column,

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

He is now diving through some of the busiest air

lanes in the world with the added

danger of a mid-air collision.

[alarm blaring]

From the cabin, lead flight attendant, John Heward,

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

I looked up, and there was Nigel 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, well, if I put me arm through the seat belt

there, I can grab both of them, and at least

we've got some sort of anchor point inside the aircraft.

[alarm blaring]

NARRATOR: Atchison, who has never flown with this crew

before, has to trust them and focus

on getting the plane to safety.

[music playing]

He now has control of the throttles.

Seward and Ogden 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 too 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.

[music playing]

In the cabin, the two other flight attendants, Sue Prince

and Simon Rogers, are trying to prepare

the passengers for what they hope will, at worst,

be an emergency landing.

Speedbird 5390.

Mayday, mayday, mayday.

Emergency depressurization on--

NARRATOR: British Airways Flight 5390 dives to 11,000 feet

in just two and 1/2 minutes, but as it levels out and slows down

to 170 miles per hour, the Captain's body is

no longer pinned to the roof.

It slides around to the side of the plane.

ALASTAIR ATCHISON: --100.

Mayday heading 195.

NARRATOR: Working his way from the back of the cabin,

flight attendant, Simon Rogers, now

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

[interposing voices]

Now the aircraft had got to flying fairly level,

Simon came up from the back.

Get yourself in the

[interposing voices]

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

and I knew he wasn't gonna let go unless he was sure that Tim

wouldn't fly out of the window.

We all had fear in our eyes.

We were all worried sick.

Because 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 Alastair then, and it was up to us

three, Simon, and John, and meself,

to hold on to grim [inaudible].

Mayday, mayday, mayday.

London, this is--

NIGEL OGDEN: All I remember is Tim's arms flailing out.

His arms seemed about six foot long,

and I'll never forget that his eyes were wide open.

His face was hitting the side of the side screen,

but he didn't blink.

And I thought to meself, and I said to John, I said,

I think he's dead.

I think he's dead.

And I said, you and Simon'll have to hold on.

I can't hold on anymore.

I can't hold on anymore.

I've lost the feeling in me arms.

And we decided to put Simon--

I said to Simon, you sit in that jump seat

and fasten yourself in.

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,

and then Simon literally put his hands on the top

to say he was holding his ankles down.

[attendants grunting]

Hey, look, what's going on?

We're gonna be all right, but I think the Captain's dead.

Well, I couldn't believe it, because he'd just told

us what a lovely day it was.

Blue skies, sunshine.

Relax and enjoy the flight.

And next minute, he's dead?

NARRATOR: Rogers and Alastair Atchison

now face one of their most difficult decisions.

What to do with the lifeless body of the Captain.

Can you hold on to him, please?

NARRATOR: But Atchison's order isn't

simply an act of compassion.

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

it would have gone close to the upper area of the wing.

It could have damaged the leading edge of the wing.

Had it gone over the wing, it could very well

have gone into the engine.

Quite a lot of damage could have been caused

by the release of the body.

So I think it was a very sensible decision to try

and keep him where he was.

NARRATOR: Atchison has managed to get the plane down to 11,000

feet, but without the Captain to help,

he's operating the plane's 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 is able to hear the voice of air traffic

control for the first time.

--requesting radar resistance onto the nearest airfield,

please.

AIR TRAFFIC CONTROLLER: Speedbird 5390, roger.

Can you accept landing at Southampton?

Speedbird 5390, I am familiar with Gatwick.

Would appreciate Gatwick.

NARRATOR: Atchison wants to land at Gatwick Airport

since he has flown there many times before.

But Southampton is nearer, and even

though he has never flown there, he

knows he has to get down fast.

--and 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, let-down 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, because everything

had gone out the window.

There was no let-down plates to look at the approach and so on.

[music playing]

NARRATOR: Only the air traffic controller can guide Atchison.

He turns toward Southampton.

[music playing]

Southampton, this is Speedbird 5390.

Do you read?

CHRIS RUNDLE (OVER 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 on to 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 pressurization failure.

Is that the only problem?

Negative.

The Captain is half out of the airplane, 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 the hairs in 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.

ALASTAIR ATCHISON (OVER RADIO): Flight attendant

holding on to him, but requesting an emergency

facility for the Captain.

I think he is dead.

Affirm.

What is your passing level?

ALASTAIR ATCHISON (OVER RADIO): Leaving flight

level 5,500 feet on 1019.

Roger, that's copied.

I'll give you a little bit more space then I'll turn

you on to a heading of 180.

Yeah, it's a full emergency.

It's a 111-

NARRATOR: Chris Rundle contacts the emergency services

at the first opportunity.

--but I'll let you know.

Could you confirm that the length of runway at Southampton

is acceptable for a 111?

Yes, it is acceptable for a 111,

and I'll give you the figures shortly.

As long as we have at least 2 and 1/2 1,000 meters,

I am happy.

CHRIS RUNDLE (OVER RADIO): I'm afraid we don't

have 2 and 1/2 1,000 meters.

Neither do Bournemouth.

We have a maximum of 1,800 meters.

5390.

NARRATOR: Atchison is concerned that the plane is

above its maximum landing weight,

being full of fuel for the journey to Malaga,

and the BAC 111 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 tires would, burst or whether he would

go off the end of the runway.

That's obviously what he was worried about when

asking for 2,200 meters.

5390.

Thank you very much.

We are three cleans and flaps 45.

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

Yes, I will indeed.

You are number one 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 one

doing all the emergency drills.

So what you actually had was the Captain hanging out the window,

at least one person hanging on to his legs,

and Alastair flying the aeroplane with nobody else

to talk to.

Speedbird of 5390, it's nine miles from touchdown.

You are clear to land.

Wind indicates 020 degrees at 1/4 knots.

Descend to height to 15 for 00 feet.

The cure fee is 1017.

Roger, sir.

Descending to 1,500 feet.

Talk me down all the way.

I need all the help I can get.

CHRIS RUNDLE (OVER RADIO): Roger you'll

be able to stop the aircraft on the runway

and evacuate the aircraft on the runway.

He must have 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.

At the point he said, he was visual with the runway,

I effectively stopped talking.

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.

CHRIS RUNDLE (OVER RADIO): Thank you.

You are clear to land.

Do you wish me to continue with any further information?

Negative.

NARRATOR: 32 minutes after takeoff, with 81 terrified

passengers, a nearly full fuel tank, and the Captain

blasted out of the window, Alastair Atchison attempts

a dangerous, difficult landing.

[music playing]

At 8:55 AM, Flight BA 5390 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.

[music playing]

I remember seeing the copilot, the man who really,

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

And is walking down the runway very slowly, shaking his head,

and he got an ambulanceman walking

with him with his arm around the shoulders of the copilot.

And the copilot was shaking his head, as if--

I remember that distinctly.

I don't know why, but I do.

[music playing]

NARRATOR: Alastair 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 no one

can be expected to survive.

[music playing]

I think these extreme conditions no one expects

to occur in their lifetime.

His survival time must have been measured in no more than tens

of minutes as he became colder and colder, and his body

systems began to shut down.

NARRATOR: Tim Lancaster's body was subjected

to a two-pronged assault.

[music playing]

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 1,000 feet of altitude causes the temperature

to drop by about 3 and 1/2 degrees,

so the temperature on the outside of the plane

would have been near zero.

The extreme wind chill also meant his body

was losing heat very rapidly.

He would have lapsed into semi-consciousness and then

unconsciousness, and as the temperature,

his core body temperature, fell, he would have

finally died as a result of the excessive

cold in that environment.

NARRATOR: Despite the trauma that Lancaster's body suffered,

there is one final twist to his story.

[music playing]

Do you know, it's only once I've ever been here,

and that was 10 years ago?

15 years ago?

NARRATOR: In the Oxfordshire countryside,

John Heward and Nigel Ogden are visiting

one of their crew members, who shared

their horrific experiences.

NIGEL OGDEN: Here he is.

Hi, guys.

John. How are you?

Nice to see you, mate.

Nice to see you, mate.

Nige, come in.

Come in. Hi.

Like when I see Pete, when you go in, you've

got to pretend that--

NARRATOR: The Captain of that flight, Tim Lancaster,

has somehow survived his horrific ordeal.

There were no fatalities on BA 5390.

That's another.

You can go on the three-day cruise across the--

NARRATOR: As his frozen, lifeless body was removed

from the plane, nobody thought that Lancaster could

have survived such punishment.

But remarkably, he was slowly beginning

to emerge from the effects of his horrific accident.

MAN: Tim, can you hear me?

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

are in hospital in Southampton.

[music playing]

Over the next few days, all the bits eventually arrive back

in my consciousness.

And I put the jigsaw together and played

the whole story for myself.

And I understood what had happened.

[music playing]

I went down there last year, but

they've changed the airports.

NIGEL OGDEN: I'm glad they did hold on, because Tim was alive.

He's a very strong man.

He most have been to survive that.

I wouldn't have been able to survive it.

[music playing]

TIMOTHY LANCASTER: That's all very dramatic.

It is, look.

NARRATOR: Tim Lancaster's survival

is little short of miraculous.

He'd been minutes away from death.

It was Alastair Atchison's flying that saved his life.

His quick-thinking and getting the plane to the ground in only

22 minutes saved Lancaster from dying

from the effects of exposure.

I like it--

NARRATOR: 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, Lancaster

had made a full recovery and was flying again.

Speedbird 5390--

NARRATOR: Of course, the Captain wasn't the only one to go

through a horrific experience.

Flying alone, battling nearly 400 mile an hour winds,

and defeating the possibility of oxygen deprivation,

Alastair Atchison's achievement in saving Flight 5390

was outstanding.

Even as the crisis is unfolding on Flight 5390,

accident investigators are 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.

[music playing]

Stuart Culling senior investigator

of the air accident investigation branch,

has little to go on.

Wind's cone 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.

NARRATOR: One of his first clues comes from the log

recovered from the plane.

He knows it 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 in Birmingham.

I wanted to find out exactly what had happened

to the aircraft before it took off,

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

manager who 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.

And he wasn't in a fit state to be interviewed.

He needed to get some sleep.

[music playing]

Stuart Culling--

Good morning.

Pleased to see you.

I was expecting you.

Yes, good.

Thank you very much.

Is this the hangar in question?

This is the main hangar, yes.

Yes.

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.

[music playing]

Hello, I'm from the AAIB.

Yes, and this is my colleague.

What I'd like to do today is just

find out what went on that--

during that shift pattern and how it went.

Thank you very much.

[music playing]

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 it was relevant.

--yourself?

You didn't delegate it to somebody else and then--

Stuart, there's a phone call for you just come in.

Oh, right.

Would you mind if I took this and--

so I took the call and found that it

was information about the windscreen, which

had been found near Didcot.

And there was something like 30 bolts found with it,

most of which were one size short in diameter, one size

too small in diameter.

NARRATOR: It is 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 111, 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 that Culling has very quickly found

the mistake and the guilty man.

STUART CULLING: --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.

No, that's not possible.

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

He was 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 and using

bolts of the wrong size.

And his-- he's absolutely shocked.

I can show you.

I can show you the bolts I got out of there.

One thing that came out was that he said, oh,

the old bolts went into a waste bin in the hangar, where

he did the job.

They may still be there.

So we rushed across to the waste bin

and found something like 80 discarded bolts.

Here.

They'll be in here.

This is where I put them.

These are the bolts.

STUART CULLING: And these are the ones you

checked against the new ones?

That's right. Yep, I took--

STUART CULLING: From the carousel?

It was really excellent evidence.

Gold as far as I was concerned.

Well, I'll take these away.

ENGINEER: OK.

[music playing]

NARRATOR: By comparing the maintenance manual to what

the engineer has told him, Culling is quickly

able to identify the first part of the story, what went wrong

the previous night when the window of the BAC 111

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.

[music playing]

NARRATOR: The engineer has come in early for his shift,

and at about 4:00 AM has gone to work

removing the old windscreen from the plane.

The hangar is full, and the plane

has been pushed against the hangar door, which makes

the windscreen hard to reach.

Stretched across the fuselage, he has problems

controlling his screwdriver.

[music playing]

The windscreen that he has taken out

has itself been fitted with the wrong length bolts,

but they are still strong enough to hold

the screen in and have survived without a hitch for four years.

But he is a conscientious engineer.

He decides that he will replace the old bolts with new ones

when he installs the new screen.

[music playing]

He chooses not to go to the parts catalog

and look up the part he needs.

Instead, he goes straight to the parts store.

Good morning.

Morning.

[music playing]

NARRATOR: There, he matches by eye new bolts with the ones

he has taken out of the screen.

[music playing]

His eye match is good, and he finds

a few fresh bolts of exactly the same types in the drawer.

What I'm after is I'll need 90 7Ds.

I'm just doing a windscreen on a 111 over there,

and I need some new bolts.

8Ds on a 111.

Well, no. These are seven.

This is a seven.

I've just taken it out.

We haven't got any sevens anyway.

OK.

Right.

NARRATOR: The store manager knows which bolts the engineer

should be looking for, but the engineer

chooses to ignore his advice.

Instead, he drives to the other side of the airport

to find a match for his bolts.

It is now about 5:15 AM, and in a dark corner of the hangar,

he continues to search for new bolts identical to the ones

he has taken out of the plane.

But in the gloom, his luck finally runs out.

He thinks they match, but they don't.

He picks bolts that are just over 0.02 of an inch

too narrow for the job.

[music playing]

Returning to the hangar, he stretches over the plane

and begins fitting these new bolts.

Working at an angle, he can't see that the new bolts

don't fit correctly.

[music playing]

Signing off his work at 6:00 AM, the engineer has managed

to get his work done on time.

The plane is now ready to be handed over to Captain

Lancaster and his crew.

[music playing]

It is a disaster waiting to happen.

[music playing]

The morning of the following day, British Airways

Flight 5390 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 1/2 ton per square foot

the pressure would reach at 35,000 feet.

This pressure was looking for a weakness, and it found it.

For Culling, finding out what happened that night

is only the first step.

No one has hidden from him what they did,

but he knows he has to go deeper to understand the reason

behind this sequence of events.

Why the engineer did what he did,

and whether this is an isolated incident or the symptom

of a bigger problem.

Accident investigation, certainly on aircraft,

comprises two parts.

The first part is, what's happened?

And that's usually relatively the easy bit.

And the second part is, why did it happen?

NARRATOR: Why did the engineer ignore

procedure, bypass the technical manuals,

and ignore helpful advice?

Culling's search for the answers is, in its own way,

revolutionary.

If we talk to people without giving them warning,

we felt we'd get more information, because they'd

be freer to discuss it.

If we gave them a formal caution as it were,

we thought that they would dry up.

Coffee? ENGINEER: Yes, please.

STUART CULLING: Great.

How was the journey?

ENGINEER: Oh, well, usual stuff.

NARRATOR: They decide to talk to the engineer

well away from the hangar in a cozy hotel room.

Well, thanks for coming in.

NARRATOR: To gain insight into the methods of the maintenance

engineers, Culling then does something

no one has done before.

He brings in a behavioral psychologist.

Is the aircraft normally in the hangar

when you're doing that?

NARRATOR: Psychologists have been used

before to try to analyze why pilots

make mistakes under pressure.

It's a discipline called human factors,

but in 1990, using human factors in engineering is unheard of.

STUART CULLING: 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 that we were trying

to get to the bottom of it.

You know the parts catalog.

When you're getting the bolts out,

do you go straight to the parts catalog, or do you just--

Not usually.

Why?

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

I just got get them up out of the carousels.

Right.

You find it's easier to do it visually.

It was in that case easier to do it visually from the bolts

you take? - Yeah.

Yeah.

Because they're the same bolts that come out.

The same ones go back in.

So same size bolts.

There's no difference.

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

Yeah, it's just replacing like with like, really.

Yeah.

Because it had been flying.

We were somewhat horrified that they admitted those things

to us, because after all, we were

officially inverted commas.

And they were quite proud of them.

We would have thought that had they used such practices,

they would have kept very quiet about it.

If I'd had to go check with the computers

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

the thing, then there was good chance

they wouldn't have been flying at the time it was meant to be.

Good.

Good.

So when you're doing the job now,

you're an experienced engineer.

It might not be by-the-book or the time

like you would train somebody who was new?

No, not usually.

We've been doing these things for years.

NARRATOR: Culling is stunned by what he is hearing,

but there are more revelations to come.

[music playing]

The engineer's dangerous approach is

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.

There's no problem with that.

It's that simple.

So you trusted that the aircraft had been flying,

so therefore, they must have been the right bolts?

Yeah.

That aircraft did a lot of hours with that windscreen.

STUART CULLING: Their whole aim was to expedite

work through their station.

They had a lot of work coming.

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.

NARRATOR: Culling and the psychologist's insights

make their way into the first draft of their report.

It says that there are systemic faults in the maintenance

procedure in Birmingham.

But under pressure from British Airways lawyers,

and because they have not carried out their investigation

following normal procedure, they are

forced to change the emphasis of their final report.

Hour by hour, 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.

And so we had to remove that from the report.

NARRATOR: The investigators have never produced

an accident report like it.

Working with a psychologist, Culling

develops 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 while being certain he

was doing the right thing.

This psychological approach takes air accident

prevention to a new level.

Through the sheer skill of the crew of BA 5390,

as well as a measure of luck, 87 people are still alive.

As a consequence of this investigation,

others may never have to go through the same ordeal.

In the aftermath of the incident,

the crew are treated as heroes.

They receive numerous awards, and

Alastair Atchison receives the coveted Gold

Medal for Airmanship.

Their colleagues also show their appreciation.

JOHN HEWARD: One of the most moving things

was to go back to Birmingham.

[music playing]

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

stopped.

And all the ground staff, and all the checking girls, and all

that just stood and applauded as we walked through the building,

and it was really quite moving at the time.

You wanted to get out of the way, so that you could--

I don't really want to do this walking

up the red carpet thing.

NARRATOR: 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 and 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 British Airways

just five months after the accident.

TIMOTHY LANCASTER: It was a special day

when I-- the first day I flew.

I decided that was what I was gonna do.

I was gonna make an effort to go back to work and get better.

So having made the decision, the rest was easy.

NARRATOR: For Nigel Ogden, the man who ran to Lancaster's aid

and held on to him for dear life, the impact of that day

is far more profound.

I think about it every day, and that is the truth.

I think about it every single day in one form or another.

Yeah.

Every single day.

[music playing]

It will affect me till the end of me days.

NARRATOR: For each of the crew, the experience

will stay with them in different ways, but common to

them all is the understanding that together,

they survived the unthinkable.