ASN Wikibase Occurrence # 229519
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| Date: | Thursday 12 July 2018 |
| Time: | 11:42 |
| Type: |  Boeing 737-8FE (WL) |
| Owner/operator: | Tigerair Australia |
| Registration: | VH-VUB |
| MSN: | 34013/1573 |
| Year of manufacture: | 2004 |
| Fatalities: | Fatalities: 0 / Occupants: |
| Aircraft damage: | None |
| Category: | Incident |
| Location: | near Sydney, NSW -
 Australia
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Sydney-Kingsford Smith International Airport, NSW (SYD/YSSY) |
| Melbourne-Tullamarine Airport, VIC (MEL/YMML) | |
| Investigating agency: | ATSB |
| Confidence Rating: |  Accident investigation report completed and information captured |
As the Boeing 737-800 climbed through 13,500 feet during a scheduled airline flight from Melbourne to Sydney, the aircraft’s cabin altitude warning horn sounded, resulting in the pilots donning oxygen masks. On hearing the alert the First Officer, who was the Pilot Flying, identified that both air conditioning pack switches were set to OFF, and immediately switched them to AUTO.
The Captain took over control of the aircraft and after the crew completed the remainder of the cabin altitude warning checklist, and with cabin pressure under control and operations normal, the flight continued to Melbourne.
The ATSB’s subsequent investigation of the incident found that normal procedures and checklists, which were designed to ensure that the aircraft is correctly configured for flight, were not completed due to a number of factors, including training, distraction, high workload, low expectancy of error, and supervision lapses.
The investigation noted that the the First Officer, who was under supervision from the Captain ahead of being checked to the line on the 737, had significant experience on other aircraft types. The First Officer had only recently joined the airline and a lengthy break in flying roles and significant gaps in the training program may not have allowed him sufficient time to consolidate the procedures to an intuitive level that was resilient to error.
As the First Officer was very experienced, the Captain may have relaxed his supervision of the First Officer, thus contributing to him not identifying the error at the time.
Accident investigation:
 |
|
Sources:
ATSB
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 30-Sep-2019 19:43 | harro | Added |
| 30-Sep-2019 19:44 | harro | Updated [Destination airport] |
Corrections or additions? ... Edit this accident description
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