Loss of pressurization Incident Boeing 737-809 (WL) B-18609,
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ASN Wikibase Occurrence # 186543
 
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Date:Sunday 17 April 2016
Time:16:49
Type:Silhouette image of generic B738 model; specific model in this crash may look slightly different    
Boeing 737-809 (WL)
Owner/operator:China Airlines
Registration: B-18609
MSN: 28407/161
Year of manufacture:1998
Fatalities:Fatalities: 0 / Occupants: 122
Aircraft damage: None
Category:Incident
Location:180nm northwest of Guam -   Guam
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Guam International Airport (GUM/PGUM)
Destination airport:Taiwan Taoyuan International Airport (TPE/RCTP)
Investigating agency: ASC
Confidence Rating: Accident investigation report completed and information captured
Narrative:
China Airlines flight CI025 turned back to Guam International Airport after a cabin pressurisation issue.
After the aircraft, a Boeing 737-800, climbed up to an altitude of 37,000 feet, a caution message "Auto Fail/Unscheduled Pressurization Change" showed up on the instrument panel. The flight crew then performed manual control procedures according to the Quick Reference Handbook. The abnormal cabin altitude persited, forcing the flight crew to immediately perform an emergency descent and turn back to Guam. A safe landing was made on runway 06R about 40 minutes later.

Findings published by the ASC:
Findings related to probable causes: A gear pin of cabin pressure system outflow valve was broken so that the outflow valve could not be controlled which resulted in abnormal cabin pressure and air turned back to Guam.

Findings related to the risks: During the Operator's so-called "the contents of the Fault Isolation Manual is incomplete" event happene [sic: happening?], the Aircraft On Ground team did not contact the Boeing for professional and effective recommendations. After the end of rescue [sic: repair?], the team did not actively inquire about the cause of failure message during troubleshooting. This indicates that the China Airlines should implement the execution of maintenance management rules.

Four safety recommendations were raised.

Accident investigation:
cover
  
Investigating agency: ASC
Report number: 
Status: Investigation completed
Duration:
Download report: Final report

Sources:

https://www.guampdn.com/story/news/2016/04/17/cabin-pressure-failure-causes-air-return-china-air/83152878/?from=new-cookie
https://www.asc.gov.tw/main_ch/docDetail.aspx?uid=227&pid=227&docid=749
flightradar24.com/data/flights/ci25/#970165a
https://www.asc.gov.tw/main_en/docaccident.aspx?acd_no=210&uid=344&pid=296

Revision history:

Date/timeContributorUpdates
18-Apr-2016 15:12 AF5541 Added
18-Apr-2016 15:14 harro Updated [Source, Narrative]
18-Apr-2016 15:15 harro Updated [Registration]
09-Jun-2016 04:14 AF5541 Updated [Destination airport]
04-Jun-2017 07:45 harro Updated [Narrative]
04-Jun-2017 07:50 harro Updated [Time]
04-Jun-2017 18:03 Aerossurance Updated [Source, Narrative]

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