Mayday (2013) s02e01 Episode Script
Blow Out
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: 5390 At the controls, a young copilot is battling to get the plane to the nearest airport.
COPILOT: Mayday! Mayday! (calls out inaudibly) THEME MUSIC For the crew of the British Airways flight from Birmingham, England, to Malaga, Spain, the 10th of June began like any other day.
Stewards Nigel Ogden and Simon Rogers, along with stewardess Sue Prince, had worked together on and off for years.
At Birmingham, all the cabin crew and all the pilots, they all knew each other, we're all on first-name terms.
The one new member of the group was Alistair Atchison.
An experienced copilot, he'd just driven down from Manchester that morning.
Come on in.
Tim Lancaster is captain.
He's been a commercial pilot for 21 years.
Well, we'd better get started, eh? 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.
These unsuspecting passengers and crew were about to begin an adventure of a lifetime.
You seem to have made yourself comfortable.
Too right! Birmingham Tower, Speedbird 5390, we're ready to start and push.
MAN ON RADIO: Speedbird 5390, cleared to start and push.
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.
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 (screams) 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.
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.
There's no time to think about the captain.
who's been blasted out of the window by pressurised air escaping from the aircraft.
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.
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 390m/h 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! (calls out inaudibly) Air Traffic Control can hear his cries for help but the storm rushing through the cockpit drowns out their replies.
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.
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.
ATCHISON: Mayday 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 170m/h, the captain's body is no longer pinned to the roof and slides round to the side of the plane.
Flight level 1-0-0.
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 II 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.
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? Uhnegative.
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 wassort 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? 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, uhflaps 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.
AIR TRAFFIC CONTROL: 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.
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 1,700 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.
- John, nice to see you.
- Nice to see you.
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, uhunderstood 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.
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.
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.
.
.
7 and 8 Once the fog clears, the lack of oxygen at that height begins to tell.
Without oxygen, at first we begin to see a reduction in their reaction speed.
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.
Flying alone, battling nearly 400m/h 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.
Umno, 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 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 half tonne per square foot 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 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.
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: 5390 At the controls, a young copilot is battling to get the plane to the nearest airport.
COPILOT: Mayday! Mayday! (calls out inaudibly) THEME MUSIC For the crew of the British Airways flight from Birmingham, England, to Malaga, Spain, the 10th of June began like any other day.
Stewards Nigel Ogden and Simon Rogers, along with stewardess Sue Prince, had worked together on and off for years.
At Birmingham, all the cabin crew and all the pilots, they all knew each other, we're all on first-name terms.
The one new member of the group was Alistair Atchison.
An experienced copilot, he'd just driven down from Manchester that morning.
Come on in.
Tim Lancaster is captain.
He's been a commercial pilot for 21 years.
Well, we'd better get started, eh? 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.
These unsuspecting passengers and crew were about to begin an adventure of a lifetime.
You seem to have made yourself comfortable.
Too right! Birmingham Tower, Speedbird 5390, we're ready to start and push.
MAN ON RADIO: Speedbird 5390, cleared to start and push.
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.
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 (screams) 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.
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.
There's no time to think about the captain.
who's been blasted out of the window by pressurised air escaping from the aircraft.
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.
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 390m/h 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! (calls out inaudibly) Air Traffic Control can hear his cries for help but the storm rushing through the cockpit drowns out their replies.
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.
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.
ATCHISON: Mayday 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 170m/h, the captain's body is no longer pinned to the roof and slides round to the side of the plane.
Flight level 1-0-0.
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 II 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.
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? Uhnegative.
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 wassort 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? 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, uhflaps 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.
AIR TRAFFIC CONTROL: 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.
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 1,700 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.
- John, nice to see you.
- Nice to see you.
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, uhunderstood 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.
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.
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.
.
.
7 and 8 Once the fog clears, the lack of oxygen at that height begins to tell.
Without oxygen, at first we begin to see a reduction in their reaction speed.
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.
Flying alone, battling nearly 400m/h 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.
Umno, 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 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 half tonne per square foot 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 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.