Introduction

On June 10, 1990, the British Airways Flight 5390 connecting Birmingham Airport in

England to go to Malaga Airport in Spain. On board are the two pilots — Captain Tim Lancaster,

with a total of 11,050 flight hours, and a copilot Captain Alastair Atchison, with 7,500 hours of

flight. The BA Flight had a total of 81 passengers and six crews.

Synopsis

Due to an explosive decompression, the left windscreen of the cockpit was detached thus

Lancaster was propelled from his seat and was fortunately grabbed by Nigel Ogden who

happened to be at the flight deck. The copilot. Alistair Atchison then put on an oxygen mask and

made an emergency descent to reach an altitude with sufficient pressure because the plane was

not equipped with enough oxygen mask for everyone. Eventually, Alistair Atchison was able to

make an emergency landing at Southampton Airport. Lancaster luckily survived with no major

injuries and were able to return to work after 5 months.

It was later found out through investigation that the 84 bolts used to install the

windscreen was too small in diameter and the rest were too short. The shift maintenance manager

was held responsible for failing to follow the British Airways Policies by installing the incorrect

bolts.

Alastair Atchison and the cabin crews were awarded the Queen’s Commendation for

Valuable Service in the Air. Atchison was a awarded a 1992 Polaris Award for his ability and

heroism.

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 FACTUAL INFORMATION
History of Flight

The accident occurred during a scheduled flight (BA 5390) from Birmingham, England

to Malaga, Spain. With 81 passengers, four cabin crew and two flight crew. The aircraft took off

from Birmingham International Airport (07:20 UTC) and the take-off was handled by Atchison.

Atchison handed the control to Lancaster as the Aircraft climbed, after which the pilots loosened

their lap belt and released their shoulder harness.

The airplane was climbing through about 17, 300 feet (07:33 UTC), and the plane is

flying over Didcot, Oxfordshire. The cabin crew was preparing to serve meals and drinks. Nigel

Ogden from the cabin crew was entering the cockpit and then a loud band was suddenly heard.

The left windshield panel on Lancaster’s side

was separated from the fuselage, hence Lancaster

was sucked out due to the decompression.

Lancaster’s knees were caught in the flight

controls which caused the autopilot to disengage,

Figure 1. Depicted image of the accident
thus causing the plane to descend. The flight

deck door was blown inward blocking the

throttle controls which caused the plane to gain speed while on a descent. Ogden who happened

to be at the cockpit rushed to Lancaster and quickly grabbed his belt, the other members of the

cabin crew secured loose objects and reassured the passengers.

Atchison immediately made a rapid descent to reach an altitude with enough air pressure

because the plane was not equipped with enough oxygen for everyone on board. After reaching

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an altitude with enough air pressure, Atchison re-engaged the autopilot and began broadcasting a

distress signal. Due to the wind noise, there was a delay in the initiation of emergency

procedures. The flight attendant Ogden who was holding on to Lancaster was now exhausted and

having frostbite from the cold so the other two members of the cabin crew John Howard and

Simon Rogers took over in holding Lancaster. The crew already thought that Lancaster was

already dead but they were holding onto him because of the possibility of him to fall to the

engine and damage it. Atchison was able to eventually get clearance for emergency landing from

the air traffic control at Southampton Airport. The aircraft landed at the Southampton Airport

(07:55 UTC). Lancaster was then sent to Southampton General Hospital to be treated from

frostbite, bruising, fractures, and shock to his right arm's left thumb and right wrist. Ogden was

also treated in the hospital from frostbite to his face, damage to one eye, and a dislocated

shoulder, apart from that, there were no other major injuries. Lancaster was able to return to

work after five months.

ANALYSIS

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 From the investigation, it was found out that 84 bolts that was used to secure the

windscreen are too small in diameter compared to the standard bolts that are meant for the plane.

The undersized bolts were unable to withstand the air pressure, hence the cause of the explosive

decompression. It was found out by the investigators that the shift maintenance manager was

responsible for the installation of the incorrect bolts that failed to follow the British Airways

Policies. The local Birmingham Airport management is also responsible for not directly

monitoring the shift manager’s working practices.

The IPC [Illustrated Parts Catalogue] was available on a microfiche reader, but was not

used to identify the part number of the bolts to be replaced, consequently a stock check, using

TIME [Total Inventory Management for Engineers], to assess the availability and location of

replacement bolts was not carried out. The Shift Maintenance Manager justified this omission by

saying that he was quite satisfied that the bolts that he had removed were the correct bolts, and

that it would take so much time to find the correct numbers in the IPC that he did not feel

justified in using the IPC in the circumstances of the job in question.

The aircraft manual calls for a torque of 15 lbf in to be applied to the bolts, which are

then retorqued to 5 lbf in after 100 flying hours. The Shift Maintenance Manager's experience

told him that many of the bolts would be found up to three turns loose during the retorque

procedure, so he decided to increase the initial torque to 20 lbf in.

The Shift Maintenance Manager's ability to properly do the windscreen fitting process

was undermined by his poor trade practices, inadequate care, failing to follow the standards, used

of unsuitable equipment.

APPENDICES

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 1.1 INJURIES TO PERSON

Crew Passengers Others Total

Fatal - - - 0
Serious 2 - - 2
Minor/None 4 81 - 85
Total 6 81 - 87

1.2 DAMAGES TO AIRCRAFT

Due to the decompression, the windscreen on the left panel was separated from the

body, thus the flight deck door was destroyed and caved in.

1.3 OTHER DAMAGES

Aside from the damages to the airplane, there were no collateral or any other damages

besides that.

1.4 AIRCRAFT INFORMATION

Aircraft Type Airbus A330-243

Operator Air Transat
ICAO Flight No. TSC236

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 Call sign TRANSAT 236 HEAVY
Registration C-GITS
Flight Origin Toronto Pearson Int’l Airport
Destination Portela Airport, Lisbon, Portugal

1.5 AERODROME INFORMATION

Southampton Airport is an international airport in Southampton, Hampshire in the

United Kingdom. The owner of the airport is AGS Airports, and the operator the

airport is Southampton International Airport Limited. The airport has an elevation

level of 44 ft above sea level, the coordinates are 50°57′01″N 001°21′24″W. The

airport is also a hub for Flybe.

THINGS I HAVE LEARNED IN AVIATION SAFETY THOUGH CAPT. JAYPEE

TAGUILING.

Well, first things first, obviously I learned about safety in terms of aviation, it is the name

of the subject after all. I was able to gain an in-depth knowledge of aviation safety thanks to

Capt. Jaypee. I learned how complex it can be, especially because of the fact that safety not only

means protection but also everything that can affect safety. Things such as culture which can

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have an effect towards the aviation safety as a whole, since I also learned that small mistakes

could have a snowball effect and lead to even bigger mistakes. I learned different behaviors that

are extremely “cancerous” or rather, an attitude that very harmful, thus ways to avoid them are

also taught to us that are needed to cast aside these hazardous attitudes. I also learned that due to

the technological advancements, most of the time, accidents are caused by human factors,

whether by the organization who made the decisions, or the mechanics who are taking care of the

aircraft’s parts, or the pilots that are responsible for flying the said aircraft. Our critical thinking

was also tested for the activities and tasks that were given by Capt. Jaypee.