All language subtitles for Air Disasters S18E13 Blow Out 1080p PMTP WEB-DL DDP5 1 H 264-maldini_track3_[eng]

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!

MAN: He's gonna crash!

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.

NARRATOR: The lives of
87 passengers and crew

are in serious and
immediate danger.

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.

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.

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.

The one new member of the
group is Alastair Atchison.

An experienced copilot,
he has just driven down

from Manchester this morning.

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.

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.

80 knots.

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.

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.

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.

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.

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.

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.

Atchison needs all his
flying experience now.

He's on his own.

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.

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.

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.

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.

NARRATOR: Atchison, who has
never flown with this crew

before, has to
trust them and focus

on getting the plane to safety.

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.

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.

Now the aircraft had got
to flying fairly level,

Simon came up from the back.

Get yourself in the

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 .

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.

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.

NARRATOR: Only the air traffic
controller can guide Atchison.

He turns toward Southampton.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

he has taken out of the screen.

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.

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.

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.

It is a disaster
waiting to happen.

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.

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.

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.

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.