ASN Wikibase Occurrence # 316102
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| Date: | Wednesday 17 November 2021 |
| Time: | 04:34 UTC |
| Type: |  Boeing 737-85R (WL) |
| Owner/operator: | SpiceJet |
| Registration: | VT-SYZ |
| MSN: | 34803/2209 |
| Year of manufacture: | 2007 |
| Fatalities: | Fatalities: 0 / Occupants: 190 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | 108 nm from Patna -
 India
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Ahmedabad-Sardar Vallabhbhai Patel International Airport (AMD/VAAH) |
| Patna Jay Prakash Narayan International Airport (PAT/VEPT) | |
| Investigating agency: | AAIB India |
| Confidence Rating: |  Accident investigation report completed and information captured |
SpiceJet flight SG391, a Boeing 737-85R, suffered a loss of cabin pressure during descent towards Patna Airport.
The flight was uneventful till cruise. However, during descent the MASTER CAUTION along with AUTO FAIL LIGHT of pressurization system illuminated. The crew did not execute the NNC actions in the prescribed order and commanded the outflow valve open in manual mode leading to annunciation of MASTER CAUTION and CABIN ALTITUDE warning. The delay by the PIC to don oxygen mask during the decompression event probably resulted in momentary incapacitation (Hypoxia) of PIC for a short duration (60-90 seconds). The crew initiated a rapid descent and declared an emergency, which was cancelled during final approach. The aircraft landed safely at Patna at 04:57 UTC.
Probable Cause of the Serious Incident
Direct Cause
The PIC did not adhere to the standard operating procedure to maintain cabin pressure during AUTO/ALT FAIL condition due to inadequate knowledge in handling of pressurization system in manual mode.
Latent cause(s)
1. Inadequate application of Crew Resource Management (CRM) principles by the flight crew.
2. Inadequacy of training in handling pressurization control and control of outflow valve in manual mode.
Accident investigation:
 |
|
Sources:
AAIB India
History of this aircraft
Other occurrences involving this aircraft
| 21 April 2017 | VT-JGV | Jet Airways | 0 | near Delhi-Indira Gandhi International Airport (DEL/VIDP) | |
non |
| Near miss | ||||||
| 19 June 2022 | VT-SYZ | SpiceJet | 0 | Patna Airport (PAT/VEPT) | |
unk |
| Bird strike | ||||||
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 28-Jun-2023 08:12 | harro | Added |
| 28-Jun-2023 08:13 | harro | Updated |
| 29-Jun-2023 15:53 | Anon. | Updated |
Corrections or additions? ... Edit this accident description
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