The 1990 British Airways flight 5390 incident, where a cockpit window blew out mid-flight and the pilot was partially ejected, stands as a dramatic reminder of how small errors can have catastrophic consequences.
While the aviation industry responded by strengthening maintenance and safety protocols, the incident offers critical lessons for process safety practitioners in the chemical and process industries. Here’s what we can learn:
The Importance of Proper Tools and Training
The engineer responsible for replacing the cockpit windscreen relied on visual inspection to select screws rather than consulting the maintenance manual or using proper tools. This decision, made with the best of intentions, led to the installation of screws that were the wrong size and lacked the necessary strength to hold the windscreen securely. This error highlights how crucial it is to ensure that those performing critical work are not only qualified but also equipped with the right tools and clear guidance. Comprehensive training and easy access to accurate procedures are essential to preventing similar mistakes.
Adhering to Established Procedures
Equally important is the need to follow established procedures and standards. In this case, the engineer’s deviation from the manual led to a catastrophic failure. For process safety practitioners, this serves as a reminder that adherence to written procedures isn’t just a formality—it’s the backbone of safety in high-risk environments. Procedures must be clear and accessible, but more importantly, they need to be reinforced through a culture that discourages shortcuts, even under time pressure.
The Need for Verification and Peer Review
Another critical aspect is verification. The engineer’s work was not independently checked, allowing the error to go unnoticed. Independent verification and peer review should be standard practice for safety-critical tasks. Creating a culture where double-checking is valued can prevent small errors from escalating into major incidents.
Avoiding the Danger of Normalising Deviance
This incident also highlights the danger of normalising deviance. The engineer relied on informal methods, likely because they had worked in the past. Over time, these deviations from standard practice became routine. For process safety practitioners, this underscores the need for vigilance. Regular audits and a commitment to identifying unsafe habits can help organisations avoid the slow drift toward complacency.
The Role of Safety Culture in Process Safety
The systemic nature of this failure—not just the individual error—brings safety culture into focus. A strong safety culture integrates process safety into every aspect of operations. It encourages open communication, accountability, and a shared commitment to excellence. Without it, even experienced teams can fall victim to preventable mistakes.
Designing for Safety and Error Prevention
Design also plays a pivotal role. The ability to install incorrect screws indicates a lack of error-proofing in the system’s design. For process safety practitioners, this is a call to action: design systems and equipment to minimise the possibility of human error. Unique fittings, automated alerts, and other error-resistant mechanisms can make a significant difference.
Embracing Continuous Improvement
Perhaps the most enduring lesson is the importance of continuous improvement. The aviation industry’s response to this incident was to revise maintenance protocols and improve oversight. This commitment to learning and evolving is a hallmark of successful safety programmes. Treating incidents and near-misses as opportunities for growth can transform challenges into progress.
Addressing Human Factors in Safety Management
Finally, human factors can never be overlooked. Decisions made under time pressure, overconfidence in informal practices, and other human elements contributed to this incident. Incorporating human factors engineering into safety management systems can help mitigate these risks, making processes more resilient and forgiving of human error.
Conclusion: Building Resilient Safety Systems
The Flight 5390 incident shows that even the most experienced professionals are not immune to errors. Experience, while valuable, must be supported by robust systems, clear processes, and checks to safeguard against mistakes. Relying solely on intuition or past success can lead to complacency, which is why it is crucial to integrate structured protocols, continuous learning, and proactive measures into every aspect of process safety. By doing so, organisations can protect their people, assets, and the environment, ensuring long-term success and resilience.