On June 10, 1990, a windshield panel flew out of a British Aircraft Corporation One-Eleven (BAC-111) short range passenger jet on British Airways flight 5390 from Birmingham to Malaga, Spain. In an instant, the captain was sucked out the window and pinned flat against the top of the aircraft; his foot happened to hook onto the control column to save him from certain death. A flight attendant held the captain’s feet while the copilot, shaken and disoriented, gained control of the jet and managed a safe landing. Miraculously, no one – including the captain – was killed. This was a common route in average conditions. How on Earth does something like this happen?
In aviation’s early history, planes didn’t fly high enough for oxygen levels in the atmosphere to be a problem. By 1920, however, technology was advanced enough that airplanes were beginning to reach altitudes where the pilots didn’t have enough oxygen to breath. The solution was a direct oxygen delivery system – early attempts used a tube to deliver oxygen from a tank right into the pilot’s mouth. It wasn’t long before methods were developed to to deliver oxygen into the sealed cockpit. Much more comfortable.
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Oxygen wasn’t the only problem plaguing those early flights, and isn’t the only vital thing at sea level that disappears with increased altitude. Equally necessary is the pressure the atmosphere exerts on our bodies. We don’t feel it, but atmospheric pressure is constantly working to keep our bodies from expanding and exploding. After the problem of oxygen delivery into the cockpit was solved in 1920 and pilots started pushing airplanes to higher altitudes, and doctors noted a dramatic swelling of their vital organs. The lack atmospheric pressure led to the use of pressure suits in high atmospheric flights.
But airlines can’t ask passengers to have and maintain their own pressure suits, so there are two things going on in a modern airplane cabin: the oxygen for breathing is pressurized to keep passengers safe and comfortable, usually to the equivalent of 8,000 to 10,000 feet above sea level.
This creates a fairly striking pressure difference between the inside and outside of the airplane. The average cruise altitude of a commercial flight is between 30,000 to 40,000 feet. As a point of comparison, it’s the rare individual who can climb Everest without the help of an oxygen tank, and the mountain’s peak is slightly lower at a little over 29,000 feet.
During flight, the higher pressure in the cabin is looking for a way out. Luckily – and smartly – most airplanes use this pressure difference to an advantage. Doors, windows, and even the cargo hold door are inward opening and create an airtight seal when the cabin pressure pushes against them. It’s like a room with a window that is screwed into the wall on the inside. You can put great pressure on the window, but the wall will hold it in place.
The BAC-111 was not designed to take advantage of the pressure difference; it actually made the pressure difference its enemy. Notably, the widow panes on the cockpit windshield were installed from the outside. They were a weak point in the airplane’s overall body on which the pressure from the cabin was exerting great force. It’s like that same room, but the window is installed on the outside. Put pressure on it now and the screws are more likely to give out. This is exactly what happened on the British Airways flight.
National Geographic’s great dramatization of the story as part of their ongoing documentary series, ‘Air Crash Investigation’ (or ‘Mayday’ for all you Canadians who recognize the format from Discovery Canada).
The flight took off from Birmingham heading south to Spain. As the plane climbed to its cruising altitude it passed through increasingly thinning atmosphere, which in turn increased the pressure difference between the inside and outside of the cabin. As the plane passed through 17,300 feet over Didcot, the pressure difference became high enough that it pushed its way out of a weak point in the airplane. The screws in the externally installed windshield gave out.
As the pressure inside the airplane rushed out to equalize the pressures between the two environments – a phenomenon known as explosive decompression – the captain was sucked out the now open window pane. His feet hooked onto the control stick, saving his life but also pitching the airplane into a steep dive and putting it into a 25 degree bank to the right. The shift caused the airplane’s speed to increase to 391 miles per hour.
Pinned against the top of the fuselage, the pilot recognized his situation and had the presence of mind to turn his face sideways out of the direct onslaught of air allowing him to get some air. But the temperature at that altitude was close to freezing – just 1.4 degrees Fahrenheit and what air he could get this limited. The assault on his body soon overcame him and he lost consciousness.
A quick-acting flight attendant came to the rescue, grabbing the pilot’s legs and holding on tight. He didn’t have the strength to pull him back inside against the rushing winds. The copilot, reacting with equal speed, took control of the unwieldy jet – the decompressing rocked the airframe. With the oxygen and pressure gone from the cabin, every life on board was suddenly in his hands. He began a rapid descent of about 4,600 feet per minute to a breathable atmosphere of 11,000 of feet. Shouting over the wind rushing into the cockpit he called an emergency to the local air traffic control in the area of Southampton who diverted him to an available runway.
The copilot managed to land without the aid of his captain or any procedures since every loose piece of material in the cockpit had blown out the window with the captain. Fighting nerves the whole way down, the landing was without incident. Save the captain who suffered broken bones and bruising and a flight attendant with bruising, scrapes, and frostbite from holding the captains legs, everyone on board was left unscathed.
The failed window pane was the obvious cause of the accident, but conclusive evidence took longer to track down; the formal investigation lasted over eighteen months.
The window pane was found about six miles west of Didcot in Cholsey. Still lodged within the window pane were the installation screws. A closer look at the recovered screws as well as those still attached to the airframe revealed an odd assortment of hardware. Of the 90 bolts that kept the window in place, 26 were designated as a product code A211-8C and six with the product code A211-7D. The parts catalogue for the BAC-111 specified the screws for window installation as product code A211-8D.
The difference between the intended screw and those two types used was measured in fractions of inches. Of the 90 bolts, 84 were 0.026 inch smaller in diameter, and six were 0.1 inch too short.
It turned out that the window had been replaced 27 hours before the flight. A worker had replaced some of the bolts. This accounted for the two types of bolts found with the windshield panel. However, it also revealed that he hadn’t looked at the parts catalogue to pick the right bolts. He chose instead bolts that looked to be a match. This uncovered a more serious problem with maintenance practices including a lack of involvement on the part of shift supervisors.
The final report made a number of safety recommendations including more rigorous training and periodic testing British Airways engineers and overall more strict quality practices.
The recommendations, however, were not enough to save the BAC-111 as an airplane. It seemed the design was inherently flawed. After its introduction in mid-1960s, the airplane experienced a handful of mishaps relating to pressurization and basic functions of pitch, yaw, and roll control. (Interestingly, the most devastating incidents occurred during flights on regional airlines in smaller countries.)
British Airways stopped flying the BAC-111 in 1998. In 2010, the European Aviation Safety Agency ruled that the airplanes were no longer eligible for a Certificate of Airworthiness. There are still some BAC-111s in service, though they are almost exclusively found in regional fleets in Africa.
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