Investigation Report, B738 emergency descent due depressurisation, near Lugano Switzerland, 4 April

Investigation Report, B738 emergency descent due depressurisation, near Lugano Switzerland, 4 April

Publication info
Author
BFU (Germany)
Category
Loss of Control Airworthiness Human Factors
Date of publication
13/03/2015

On 4 April 2012, the cabin pressurisation controller (CPC) on a Boeing 737-800 failed during the climb passing FL305 and automatic transfer to the alternate CPC was followed by a loss of cabin pressure control and rapid depressurisation because it had been inadvertently installed with the shipping plug fitted. An emergency descent and diversion followed. The subsequent Investigation attributed the failure to remove the shipping plug to procedural human error and the poor visibility of the installed plug. It was also found that the pressurisation system ground test after CPC installation was not suitable to detect the error.

SKYbrary Partners:

Safety knowledge contributed by: