Event Details


Title:Explosive decompression on climb, Report on the accident to BAC One-Eleven, G-BJRT over Didcot, Oxfordshire on 10 June 1990
Micro summary:This BAC One-Eleven experienced a loss of the captain's window, a decompression, and the captain being sucked partially out.
Event Time:1990-06-10 at 0733 UTC
File Name:1990-06-10-UK.pdf
Publishing Agency:Aircraft Accident Investigation Board (AAIB)
Publishing Country:United Kingdom
Report number:EW/C1165
Pages:69
Site of event:Climb, 17,300'
Latitude/Longitude:54 34'N 010 10'W
Departure:Birmingham International Airport, West Midlands, England
Destination:Southampton Airport, Southampton, Hampshire, England (Diversion)
Airplane Type(s):BAC One-Eleven
Flight Phase:Climb
Registration(s):G-BJRT
Operator(s):British Airways
Type of flight:Revenue
Occupants:0
Fatalities:0
Serious Injuries:0
Minor/Non-Injured:0
Other Injuries:0
Executive Summary:The accident happened when the aircraft was climbing through 17,300 feet on departure from Birmingham International Airport en route for Malaga, Spain. The left windscreen, which had been replaced prior to the flight, was blown out under effects of the cabin pressure when it overcame the retention of the securing bolts, 84 of which, out of a total of 90, were of smaller than specifieddiameter. The commander was sucked halfway out of the windscreen aperture and was restrained by cabin crew whilst the co-pilot flew the aircraft to a safe landing at Southampton Airport.

The following factors contributed to the loss of the windscreen:-

A safety critical task, not identified as a 'Vital Point', was undertaken by one individual who also carried total responsibility for the quality achieved and the installation was not tested until the aircraft was airborne on a passenger carrying flight.

The Shift Maintenance Manager's potential to achieve quality in the windscreen fitting process was eroded by his inadequate care, poor trade practices, failure to adhere to company standards and use of unsuitable equipment, which were judged symptomatic of a longer term failure by him to observe the promulgated procedures.
Learning Keywords:Operations - Maintenance
Operations - Pilot incapacitation
Operations - Rapid Depressurization
Systems - Pressurization
Consequence - Damage - Airframe or fuselage

 




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