ASN Wikibase Occurrence # 144840
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| Date: | Wednesday 4 April 2012 |
| Time: | |
| Type: |  Boeing 737-8AS (WL) |
| Owner/operator: | Ryanair |
| Registration: | EI-DAH |
| MSN: | 33546/1269 |
| Year of manufacture: | 2003 |
| Fatalities: | Fatalities: 0 / Occupants: 140 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Near Frankfurt-Hahn Airport - EDFH -
 Germany
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | LIME |
| EGNX | |
| Investigating agency: | BFU |
| Confidence Rating: |  Accident investigation report completed and information captured |
At 10:56 hours local time, the airplane took off from Bergamo Airport (LIME), Italy on a regular flight (FR1703) to East Midlands (EGNX), United Kingdom. Six crew members and 134 passengers were
aboard the airplane.
About 13 minutes after take-off, the airplane was in climb above the Swiss Alps approximately 30 NM north of Lugano in Swiss airspace when the crew noticed a sudden change in cabin pressure. They reported it manifested through a draft, a decrease in temperature and pressure in the ears. The indication for the cabin rate change had been at the maximum climb indication of 4,000 ft/min and the cabin altitude exceeded 10,000 ft. The crew donned their oxygen masks and the Pilot in Command (PIC) requested completion of the Cabin Altitude Warning/Rapid Depressurization checklist.
At 11:11 the crew initiated an emergency descent and the co-pilot reported via radio: "Mayday, mayday, mayday [...], we have a rapid depressurization. Emergency descent. Descending to [...] next would be flight level one hundred, turning left on heading two eight five." The controller answered: "[...] roger, mayday is observed."
Immediately afterwards the airplane began to descent from FL308 and turned north-west. Initially the rate of descent reached more than 6,000 ft/min and after about 20 seconds decreased to about 4,000 ft/min. At the beginning of the emergency descent the airplane had a brief airprox (4.5 NM horizontally and about 325 ft vertically) with an Airbus A319 flying at FL300 also in a northern direction.
At 11:16 the airplane stopped the descent at FL100. The crew then decided to divert to Frankfurt-Hahn Airport. The airplane landed there without further problems.
One passenger had suffered a ruptured ear drum; twelve other passengers were treated for earaches.
The Serious Incident was caused by the following:
Immediate Causes:
- Due to an omission during the installation of the cabin pressure controller the shipping plug was not removed from the static port as required by written procedure.
- During the flight a pressure difference was measured and the Out-Flow Valve (OFV) opened which resulted in rapid decompression.
Systemic Causes:
- The shipping plug was not clearly noticeable and did not carry a tag.
- The pressurisation system ground test after installation was not suitable to detect the error.
Accident investigation:
 |
|
Sources:
https://www.bfu-web.de/DE/Home/homepage_node.htmlEN/Publications/Investigation%20Report/2012/Report_12_FX003_B737_Lugano_Decompression.pdf?__blob=publicationFile
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 05-Apr-2012 23:02 | saf7670 | Added |
| 06-Apr-2012 02:05 | harro | Updated [Date, Aircraft type, Registration, Cn, Location, Departure airport, Destination airport, Source, Narrative] |
| 08-Apr-2012 06:14 | Alpine Flight | Updated [Aircraft type, Location, Departure airport, Destination airport, Source, Narrative] |
| 21-Apr-2015 19:29 | harro | Updated [Total occupants, Source, Narrative] |
| 28-Jul-2018 07:33 | roxannebrownlee | Updated [Operator] |
Corrections or additions? ... Edit this accident description
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