Loss of pressurization Serious incident Boeing 737-490 ZS-JRM,
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ASN Wikibase Occurrence # 229107
 
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Date:Tuesday 20 August 2019
Time:18:25 UTC
Type:Silhouette image of generic B734 model; specific model in this crash may look slightly different    
Boeing 737-490
Owner/operator:FlySafair
Registration: ZS-JRM
MSN: 28890/3006
Fatalities:Fatalities: 0 / Occupants: 140
Aircraft damage: Minor
Category:Serious incident
Location:E of Cape Town -   South Africa
Phase: En route
Nature:Passenger - Scheduled
Departure airport:Cape Town International Airport (CPT/FACT)
Destination airport:Durban-King Shaka International Airport (DUR/FALE)
Investigating agency: CAA S.A.
Confidence Rating: Accident investigation report completed and information captured
Narrative:
The aircraft took off from runway 19 at Cape Town Airport as flight SFR461 to Durban. After take-off, it turned out left. At approximately 18:15 UTC with the aircraft passing through 10500 feet above the ground, the aircraft was cleared by the radar controller to climb to FL330, which was acknowledged by the crew.
At approximately 18:24 UTC the aircraft was climbing through FL310. Then the flight crew members heard two loud noises originating from the rear of the aircraft. Immediately afterwards the pressurization indicated a gradual climb in the cabin and a few seconds later it became uncontrollable and a Cabin Altitude Warning activated. The crew then initiated the memory items for a rapid descent.
The aircraft was cleared for the emergency descent and commenced with a right descending turn to FL100. At approximately 18:31 the crew levelled off the aircraft at FL100 and were given vectors back to Cape Town by the radar controller. During the emergency descent the oxygen masks deployed automatically in the cabin as this was confirmed by the cabin crew. The two flight crew members used their oxygen masks during the incident. The crew then assessed the situation but could not determine exactly what had happened at that stage.
The aircraft landed safely on runway 19 at approximately 18:57. No one on-board the aircraft was injured.
An inspection of the aircraft later showed that a section of the aft cargo door pressure seal had failed. During the decompression, inside of the aft cargo hold area, a section of the had ceiling partially collapsed.

Probable Cause:
The rapid decompression was caused by the failure of the aft cargo door pressure seal. The failure of the pressure seal was most likely attributed to manhandling of the door during cargo/baggage handling, which is conducted manually (by hand) before and after each flight.

Accident investigation:
cover
  
Investigating agency: CAA S.A.
Report number: 
Status: Investigation completed
Duration: 6 months
Download report: Final report

Sources:

S.A. CAA

Revision history:

Date/timeContributorUpdates
18-Sep-2019 12:09 harro Added
18-Sep-2019 12:10 harro Updated [Location]
20-Sep-2019 19:34 Anon. Updated [Narrative]
18-Feb-2020 18:42 harro Updated [Source, Narrative, Accident report, ]

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