B733, en-route, north of Narrandera NSW Australia, 2018

B733, en-route, north of Narrandera NSW Australia, 2018

Summary

On 15 August 2018, a Boeing 737-300SF crew concerned about a small residual pressure in a bleed air system isolated after a fault occurred en-route then sought and were given non-standard further troubleshooting guidance by company maintenance which, when followed, led directly and indirectly to additional problems including successive incapacitation of both pilots and a MAYDAY diversion. The Investigation found that the aircraft concerned was carrying a number of relevant individually minor undetected defects which meant the initial crew response was not completely effective and prompted a request for in-flight assistance which was unnecessary and led to the further outcomes.

Description

On 15 August 2018, the crew of a Boeing 737-300SF (VH-XMO) being operated by Qantas-owned Express Freighters Australia on a non-scheduled domestic cargo flight from Brisbane to Queensland in unrecorded night meteorological conditions were concerned that after responding to a bleed air leak indication, the system concerned was not completely isolated. A series of further ad-hoc actions were then followed by circumstances which prompted an emergency descent and a MAYDAY diversion to Canberra with temporary incapacitation of the Captain and then incapacitation of the First Officer. Both pilots passed all heath checks after completing the flight.

Investigation

An Investigation into the event was carried out by the Australian Transport Safety Bureau (ATSB). Relevant data was obtained from the FDR but the CVR was not isolated before being powered up by maintenance personnel at Canberra engaged in rectifying the reported fault and relevant data was overwritten. 

It was noted that the Captain had a total of approximately 4,500 hours flying experience which included 3,400 on type and had been a company employee for about 8 years, initially as a First Officer before gaining his command in 2018. He was also a simulator and a 737 ground training instructor with the company. The First Officer had a total of approximately 5,000 hours flying experience which included 700 hours on type and had been a company employee for almost 5 years. 

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