Three years after the unlawful killing of a passenger in its care, why hasn’t British Airways held an inquiry into what went wrong? What are the consequences of its inaction?

Three years ago today a man called Jimmy Mubenga was unlawfully killed on a British Airways plane. This past July, after an eight week Inquest, the Coroner,  Karon Monaghan QC, reported that the cabin crew had failed to help Jimmy Mubenga, despite their “thorough and precise training and guidance” regarding what to do in a medical emergency.

Monaghan criticised British Airways for failing to hold an inquiry in the years since Mubenga’s death. She urged the company to put that right. They had 56 days to respond.

On Tuesday I wrote to West London Coroner’s Court asking to see the company’s formal response. The Coroner’s office emailed back a letter from Captain Tim Steeds, Director of Safety and Security at British Airways. A sorry little note, dated 25 September 2013, it reads, in full:

‘We have considered your comments made at Recommendation 6 and have determined that the most appropriate course of action is to meet with the Civil Aviation Authority, as the industry regulator for such matters, to review your recommendations, the actions of the cabin crew and BA’s policies. Following the meeting BA will address any issues which emerge.’

Why hasn’t British Airways tried to find out what went wrong? Last week I asked them. They said:

“We cooperated fully with the Coroner’s enquiries during an 8 week inquest. The transcripts of the Inquest and our response to the Coroner’s Rule 43 report are publicly available.”

I’ve been reviewing the transcripts. (All links in this article go to PDFs).

A calm and well presented detainee

Jimmy Mubenga, a healthy 46 year old, the father of five young children, boarded a British Airways plane at Heathrow Airport on the evening of 12 October, 2010. He was being deported to Angola, escorted by three guards from G4S, a security company working under contract to the Home Office.

The guards, who were paid by the hour, stood to lose £170 each if the deportation did not go ahead as planned. British Airways faced financial penalties if the flight was delayed.

In the pre-flight briefing, according to BA purser Louise Graham, the cabin crew were told that the G4S guards alone were responsible for the care of Jimmy Mubenga. The crew should “leave them to get on with whatever they need to deal with”.

Graham recalled that cabin services director Peter Walsham said that detainees:

“can very often kick off before take-off, that’s perfectly normal, and that they’ll settle down. They always settle down after take off so just ignore that and — what else did he say? Yeah, just to not intervene in any way”.

Jimmy Mubenga and the three G4S guards were the first passengers to board — at around 19:10 hrs.

Louise Graham said: ”I remember being quite shocked because he was very, very calm and well presented.” She had assumed that a man being deported to Angola escorted by three guards “must have done something pretty awful, i.e. a terrorist, a rapist, insane or a killer”.

(In fact, Jimmy Mubenga got a two-year sentence for assault in 2006. He had no other convictions. In Britain, a non-EU immigrant who gets a custodial sentence of 12 months or more is automatically deported.)

Not long after boarding, Mubenga went to the lavatory. He called his wife on his mobile phone. One guard kept his foot in the door. What happened next is unclear.

“All of a sudden I heard this horrific howl,” said Graham. “Like howl and they all came — all sort of tumbled on top of him . . . The three guards enveloped him.”

Senior G4S guard Stuart Tribelnig (a man who, by the way, had a string of racist texts on his mobile) told the Inquest:

“I was lunged at. I’m not sure how I was lunged at, but my shirt was ripped open.”

The guards forced Mubenga into a seat at the rear of the plane. They pulled his hands behind his back, wrestling him into rigid bar handcuffs.

Louise Graham said that she and a stewardess called Ann Marie McMillan shouted to passengers (who were boarding) to get back. She said Ann-Marie was “very upset . . . anxious, very anxious, and frightened”, and wanted to get off the plane.

From start to finish the guards restrained Jimmy Mubenga for between 30 and 40 minutes — as the remaining passengers boarded, as the crew performed the safety presentation, as the plane pulled away from the stand.

Passenger Thomas Buckley reckoned one guard “had his knee pressed against the deportee for about ten minutes”.

Mubenga cried out repeatedly that he could not breathe, that the guards were killing him. He pleaded for help. Nobody helped him.

Louise Graham claimed that she conveyed concerns about Jimmy Mubenga up the chain of command. She was told that the Captain said Mubenga was likely “faking it” and might have been to RADA (the drama school). The Captain denied saying that.

Soon after the plane left the stand at 20:11 hrs, Jimmy Mubenga fell quiet. Then he stopped breathing.

Thomas Buckley said that the guards “sat up the deportee. I could see clearly his head was leaning to the right, his eyes were wide open and his mouth was hanging open a little bit. I turned to the guy next to the window in 38K and said, ‘I think that guy’s dead’.”

The G4S guards formally alerted the crew that something was wrong at about 20:20 hours. At 20:22 a call for emergency assistance was made to the control tower. Still, nobody on the plane helped Jimmy Mubenga. He remained in his seat, quiet, head back.

As the plane returned to the stand, no public announcement was made to ask for assistance from doctors or nurses who might be on board. Did the crew give first aid?

Captain Michael Fenech-Soler told the Inquest:

“Negative, because at that time there was no obvious concern. They still weren’t sure whether he was in a serious condition or not. At that point we assumed he was either faking it or he was unconscious but he was breathing.”

There was a defibrillator on board. Cabin crew had been trained to use it. Nobody did. Jimmy Mubenga remained in his seat.

The plane arrived back at the stand. Paramedics rushed on board, reaching Jimmy Mubenga just after 20:38. They immediately took him from his seat, laid him on the floor, cleared his airway, tried CPR and defibrillation.

It was too late for all that.

The Coroner said it seemed likely that Jimmy Mubenga had died in his seat before the paramedics arrived, that he had not been breathing and had not a pulse for some time.

The Inquest jury found that Jimmy Mubenga had been “unlawfully killed”, that one or more of the guards had pushed or held him down “in an unlawful manner”. They said the guards “would have known that they would have caused Mr Mubenga harm in their actions, if not serious harm”.

Lessons learned, or not

After the Inquest, the Coroner’s “Rule 43 Report” criticised the Home Office, G4S and British Airways. Such reports are intended to derive lessons from Inquests and to help prevent future deaths.

Why the cabin crew failed to help Jimmy Mubenga despite their “very thorough and precise training and guidance” was “not easy to understand”, the Coroner said. The crew seemed to have absorbed the guards’ belief that detainees would feign illness to avoid deportation. There was a “genuine confusion amongst cabin crew as to their role in the case of a deportee”. The evidence suggested that they deferred to the G4S guards.

She expressed surprise that “British Airways did not conduct any inquiry or review into the events on the plane and in particular into why there was no intervention from cabin crew.” She went on:

“It meant that they did not avail themselves of the opportunity to learn lessons, including by investigating the reasons for the response of the cabin crew. The evidence at the Inquest indicates that British Airways still do not consider such an inquiry necessary. I disagree.”

The Coroner’s formal recommendation was:

“British Airways should conduct a review into the actions of cabin crew at the time of Mr Mubenga’s death, and in particular the failure to intervene to administer first aid, and address any issues that emerge.”

We have seen BA’s response to that.

Moving out of public sight

Had BA investigated its conduct towards Jimmy Mubenga, it might have helped reduce the risk of harm to men, women and children being deported by the Home Office. Instead, British Airways simply passed the business on to its competitors.

After Jimmy Mubenga’s death, British Airways informed the Home Office that it would no longer carry certain numbers and classes of detainees. In the first five months of 2013 British Airways carried 39 detainees, compared to 1,394 in 2008, the Coroner said.

Three years on, how is the deportation business?

On Wednesday night, the Home Office deported 60 people to Nigeria on a specially commissioned charter flight. Last week another mass deportation charter flight left for Pakistan. Asylum-seekers said that the scale and speed of the mass roundups left people unable to get legal advice.

Medical staff on Home Office deportation flights are from Armatus Medical Services, part of the security and surveillance group Armatus Risks. The guards are from Tascor. That’s the new name for Reliance, the company that won the Home Office contract from G4S, retaining many G4S personnel.

The truth about what happened to Jimmy Mubenga came to light only after passengers responded to an appeal for information (sent via Twitter) from the Guardian reporter, Paul Lewis.

Passengers’ testimony contradicted the official story that Jimmy Mubenga had just fallen ill on the plane. The Home Office initially said he had been “taken ill”. G4S claimed he “became unwell”.

One feature of Home Office charter flights is the absence of fare-paying passengers. In other words, there are no independent witnesses aboard.

From Open Democracy