Final Report B738 (VH-YQR), en-route SW of Brisbane Australia, 6 September 2023

Final Report B738 (VH-YQR), en-route SW of Brisbane Australia, 6 September 2023

Publication info
Author
ATSB Australia
Category
Accident Reports Loss of Control Human Factors
Date of publication
29/11/2024

On 6 September 2023, control of a Boeing 738-800 was temporarily lost approaching cruise altitude when, on reaching to unlock the flight deck door after a cabin crew access request, the Captain operated the rudder trim switch to its full travel. Neither pilot recognised the error and an EGPWS Alert followed as left bank increased towards its maximum autopilot-engaged limit of 42°. This prompted successful upset recovery action but the underlying cause was only recognised after the First Officer suggested checking the rudder trim position. Contrary to Company procedures, prior positive identification of the intended switch had not preceded activation.

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